Clinical Research

Response of Human Dental Pulp Capped with Biodentine

and Mineral Trioxide Aggregate
Alicja Nowicka, DDS, PhD,* Mariusz Lipski, DDS, PhD,† Miros1aw Parafiniuk, MD, PhD,‡
Katarzyna Sporniak-Tutak, DDS, PhD,§ Damian Lichota, DDS, PhD,*
Anita Kosierkiewicz, MD, PhD,jj Wojciech Kaczmarek, DDS, PhD,*
and Jadwiga Buczkowska-Radli
nska, DDS, PhD*

Abstract
Introduction: Biodentine is a new bioactive cement that
is similar to the widely used mineral trioxide aggregate
(MTA). It has dentin-like mechanical properties, which
T he application of biocompatible materials on exposed pulp protects the pulp-dentin
complex against chemical irritation by operative procedures, toxicity of the material
used, and bacterial penetration due to microleakage (1–5). Numerous studies have
may be considered a suitable material for clinical indica- shown that Ca(OH)2 should be the material of choice among the available pulp-
tions of dentin-pulp complex regeneration such as direct capping materials (6–8). However, it has been reported that Ca(OH)2 does not
pulp capping. The purpose of the present study was to adhere to dentin and dissolves over time, and dentin bridges adjacent to the material
compare the response of the pulp-dentin complex in may contain multiple tunnel defects (9–12).
human teeth after direct capping with this new tricalcium Studies have shown that mineral trioxide aggregate (MTA) may be used as an alter-
silicate–based cement with that of MTA. Methods: native to Ca(OH)2 for treating pulp wounds (2, 13). MTA stimulates formation of dentin
Pulps in 28 caries-free maxillary and mandibular perma- bridges faster than calcium hydroxide (2, 11, 13–15), consequently leading to pulp
nent intact human molars scheduled for extraction for healing, and results in high success rates in clinical procedures (13–16). However,
orthodontic reasons were mechanically exposed and as- in research by Iwamoto et al (6), no significant differences in clinical and histologic
signed to 1 of 2 experimental groups, Biodentine or results between MTA and calcium hydroxide were noted. Also, 2 randomized controlled
MTA, and 1 control group. Assay of periapical response studies have shown that MTA may result in similar clinical outcomes as calcium
and clinical examination were performed. After 6 weeks, hydroxide after capping caries pulp exposures (7, 8). MTA is a bioactive,
the teeth were extracted, stained with hematoxylin- biocompatible, antibacterial material with unique stability and high sealing ability
eosin, and categorized by using a histologic scoring (6, 11, 13–17). However, MTA is reportedly difficult to use because of its long
system. Results: The majority of specimens showed setting time, poor handling properties, high material costs, and the discoloration
complete dentinal bridge formation and an absence of potential of dental tissue (17, 18). Many attempts have been made to improve the
inflammatory pulp response. Layers of well-arranged clinical manageability of MTA by adding a setting accelerator or a dual functional
odontoblast and odontoblast-like cells were found to modifier (19, 20). The addition of CaCl2 to MTA enables an increased immediate pH
form tubular dentin under the osteodentin. Statistical value and decreased setting time and improves the mechanical properties (1, 19,
analysis showed no significant differences between 20). To prevent discoloration, the manufacturer introduced a new MTA formula with
the Biodentine and MTA experimental groups during an off-white color (18), but white MTA has a significantly slower setting time compared
the observation period. Conclusions: Within the limita- with gray MTA (21).
tions of this study, Biodentine had a similar efficacy in Biodentine (Septodont, Saint Maur des Foss
es, France) is a new calcium silicate–
the clinical setting and may be considered an interesting based restorative cement with dentin-like mechanical properties, which can be used as
alternative to MTA in pulp-capping treatment during a dentin substitute on crowns and roots similar to how MTA is used (3, 4, 22–26). It has
vital pulp therapy. (J Endod 2013;39:743–747) a positive effect on vital pulp cells and stimulates tertiary dentin formation (3, 4, 26, 27).
In direct contact with vital pulp tissue, it also promotes formation of reparative dentin
Key Words (3, 26). Biodentine consists of a powder and liquid. The powder mainly contains
Biodentine, direct pulp capping, histology, MTA, pulpal tricalcium and dicalcium silicate (3CaO SiO2 and 2CaO SiO2), the principal
reaction component of Portland cement, as well as calcium carbonate (CaCO3). Zirconium
dioxide (ZrO2) serves as contrast medium. The liquid consists of calcium chloride
(CaCl2$2H2O), which is used as a setting accelerator and water-reducing agent in
From the *Department of Conservative Dentistry, aqueous solution with an admixture of polycarboxylate (a superplasticizing agent)
†
Department of Preclinical Conservative Dentistry and Preclin- (3, 26). The consistency of Biodentine is similar to that of phosphate cement. The
ical Endodontics, ‡Department of Forensic Medicine, material can be applied directly in the restorative cavity with a spatula as a bulk
§
Department of Dental Surgery, and jjDepartment of Pathology,
Pomeranian Medical University, Szczecin, Poland.
dentin substitute without any conditioning treatment (3, 22–26).
Address requests for reprints to Dr Alicja Nowicka, Pomer- The enhanced clinical manageability of MTA may be more convenient for dentists
anian Medical University, Department of Conservative during endodontic treatments; however, it is important to note that changes in the
Dentistry, Al.Powsta
nc
ow Wlkp. 72, 70–111 Szczecin, Poland. chemical components of MTA may adversely affect its physical and possibly its bioactive
E-mail address: [email protected] properties. In vivo studies are required to understand the pulp response when MTA is
0099-2399/$ - see front matter
Copyright ª 2013 American Association of Endodontists. used for direct pulp capping. Studies on animal teeth (1, 12, 14, 19) and human teeth
http://dx.doi.org/10.1016/j.joen.2013.01.005 (2, 5–8, 10, 11, 13, 15, 16) have demonstrated the various effects of applying MTA as

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Clinical Research
a pulp-capping agent; to our knowledge, no clinical investigation has before extraction to observe signs of periapical pathology. The length of
compared Biodentine and MTA in humans, although one animal study the treatment period was 6 weeks.
has been published (26). The teeth were extracted as atraumatically as possible by a desig-
The purpose of the present study was to evaluate the clinical, nated oral surgeon (K.S-T.) in the Department of Dental Surgery.
radiographic, and histologic responses of the pulp-dentin complex
after direct capping with the new tricalcium silicate–based cement Histologic Examination
and MTA in human teeth. The null hypothesis was that there were After fixation for 2 weeks in 10% buffered formalin solution, the
no differences in the pulp-dentin complex response to 2 capping specimens were demineralized in a decalcifying solution containing
materials (Biodentine versus MTA) applied as a direct pulp cap in 10% nitric acid and were embedded in paraffin. Two- to 3-micron-thick
human teeth. serial sections in the linguobuccal plane of the paraffin-embedded teeth
were stained with hematoxylin-eosin. The Brown and Brenn technique
Materials and Methods was used to stain bacteria. Presence of stained bacteria was analyzed in
the specimens along the cavity walls, within the cut dentinal tubules and
Operative Procedure
the dental pulp.
Twenty-eight intact human caries-free maxillary and mandibular Coded samples were used throughout the study to avoid possible
third molars scheduled for extraction for orthodontic reasons were bias. By using an optical microscope (Carl Zeiss Imager D1 Axio, Goet-
selected in 18 patients ranging in age from 19–28 years. Subjects tingen, Germany) connected to a high-resolution video camera (Axio
were treated in accordance with the Helsinki declaration. Patients Cam MRc5; Carl Zeiss Micro imaging, Thornwood, NY), samples
received thorough explanations concerning the experimental rationale, were evaluated under normal and ultraviolet light by using 38 HE
clinical procedures, and possible complications of the procedure. All eGFP and 43 HE Cy 3 filters by an experienced oral pathologist (M.P.).
experimental procedures were reviewed and approved by the Local The amount of hard tissue formation at the interface of the capping
Ethical Committee, Pomeranian Medical University, Szczecin, Poland material (continuity, morphology, and thickness), pulp inflammation
(approval number KB–0012/39/11). (type, intensity, and extension), and other histologic features of the
Before the operative protocol, each tooth was radiologically pulp tissue including the odontoblast cell layer and bacterial penetra-
examined to exclude the presence of caries or periapical tion were determined according to the modified criteria by Faraco
pathology. A standardized operative procedure was followed in et al (14) and Medina et al (28). Each histomorphologic section was
both experimental groups. Thermal testing (K€altespray; M&W scored from 1–4, with 1 representing the most desired result and 4 rep-
Dental GmbH, B€udingen, Germany) and electric sensitivity testing resenting the least desired result.
(Vitality Scanner pulp vitality tester; Sybron Endo, Orange, CA) For continuity of the dentinal bridge, 1 = complete dentin bridge
were performed to assess pulp vitality. Before cavity preparation, formation, 2 = partial/incomplete dentin bridge formation extending to
teeth were mechanically cleaned and disinfected with 0.2% chlo- more than one-half of the exposure site but not completely closing the
rhexidine solution. After local anesthesia and rubber dam applica- exposure site, 3 = initial dentin bridge formation extending to not more
tion, occlusal Class I cavities were prepared by using round sterile than one-half of the exposure site, and 4 = no dentin bridge formation.
diamond burs at high speed under air-distillated water spray For morphology of dentinal bridge, 1 = dentin or dentin associ-
coolant. An exposure of approximately 1.2 mm in diameter was ated with irregular hard tissue, 2 = only irregular hard tissue deposi-
made with round carbide burs (4 1.2 mm) under air- tion, 3 = only a thin layer of hard tissue deposition, and 4 = no hard
distillated water cooling. New burs were used during each oper- tissue deposition.
ation. Bleeding was controlled with saline irrigation, and a sterile For thickness of dentinal bridge, 1 = >0.25 mm, 2 = 0.1–0.25
cotton pellet was placed onto the pulp exposure sites. mm, 3 = <0.1 mm, and 4 = partial or absent bridge. The thickness
The teeth were divided into 2 experimental groups, Biodentine of dentinal bridge was measured at the thickest, thinnest, and midmost
(n = 11) or MTA (n = 11), and 1 control group (n = 6). In group point areas of the continuous dentin bridge. The average of the 3 values
I, pulps of teeth were capped with Biodentine according to the manu- was calculated.
facturer’s recommendations. Biodentine was also used for temporary For type of pulp inflammation, 1 = no inflammation, 2 = chronic
restoration so that the entire cavity was filled with bioactive cement. In inflammation, 3 = acute and chronic inflammation, and 4 = acute
group II, exposed pulps and the surrounding dentin were capped with inflammation.
a 2-mm-thick layer of ProRoot White MTA (Dentsply, Tulsa Dental, For intensity of pulp inflammation, 1 = absent or very few inflam-
Tulsa, OK) according to the manufacturer’s recommendations. After matory cells; 2 = mild, defined as an average of <10 inflammatory cells;
placing the MTA, the operator laid a flat, water-moistened cotton pellet 3 = moderate, defined as an average of 10–25 inflammatory cells; and 4
directly over the material and provisionally restored the tooth with = severe, defined as an average >25 inflammatory cells.
glass ionomer cement (Ketac Molar; 3M ESPE, Seefeld, Germany). For extensity of pulp inflammation, 1 = absent; 2 = mild, defined
Patients in both groups returned to the clinic for clinical examinations as inflammatory cells only next to dentin bridge or area of pulp expo-
and placement of the final composite restoration after 7 days. The sure; 3 = moderate, defined as inflammatory cells observed in part of
operator also verified the setting of MTA. All procedures were per- coronal pulp (in one-third or more of the coronal pulp or in the mid-
formed by one experienced operator (A.N.) in the Department of pulp); and 4 = severe, defined as all coronal pulp is infiltrated or
Conservative Dentistry. necrotic.
Six intact teeth were selected as the control group (group III), For odontoblastic layer, 1 = palisade pattern of cells, 2 = presence
which received no exposure and pulp capping. of odontoblast cells and odontoblast-like cells, 3 = presence of only
odontoblast-like cells, and 4 = absent.
Clinical Examination For bacterial penetration, 1 = absence of stained bacterial profiles
Patients were also asked about postoperative sensitivity or pain in any part of the sections, 2 = presence of stained bacterial profiles
throughout the study period. Thermal testing and electric sensitivity along the coronal or apical walls of the cavity, 3 = presence of stained
testing were performed to assess pulp health. Radiographs were taken bacterial profiles within the cut dentinal tubules or axial wall of the

744 Nowicka et al. JOE — Volume 39, Number 6, June 2013

 Clinical Research
cavity, and 4 = presence of stained bacterial profiles within the dental Regarding the histologic evaluation criteria, our investigation
pulp. showed that there was no statistically significant difference between
the responses of teeth to Biodentine compared with MTA as a pulp-
capping agent (P > .05).
Statistical Analysis
The results of the histopathologic evaluation were statistically
analyzed by using the Mann-Whitney U test. A P value <.05 was consid- Discussion
ered statistically significant. This study presents a light microscopic analysis comparing Bio-
dentine with MTA in the pulpal response to direct pulp capping in
Results healthy human third molars. The findings of our study indicate that
iatrogenic pulp defects treated with both calcium silicate cements are
After treatment, 7 patients (4 with Biodentine and 3 with MTA)
essentially free from inflammation and become covered with compact,
complained of spontaneous minor pain, mostly on the day of surgery.
dentin-like hard tissue bridges. On the other hand, this study presents
Other patients reported no particular symptoms during the experi-
comprehensive data on the bridge and pulpal inflammation with
mental time period. Before extraction, all teeth were cold-sensitive
a similar outcome of pulp capping with Biodentine and MTA. Thus,
and electro-sensitive and had vital pulp. In addition, no periapical
the null hypothesis that there are no differences in the pulp-dentin
pathologies were revealed by radiography before the clinical procedure
complex response to the 2 capping techniques (Biodentine and
and extraction.
MTA) as a direct pulp capping in human teeth can be accepted.
Histologic evaluation of teeth showed that both materials were well
Handling characteristics are important when considering any
tolerated by the pulp tissue. Results of all the specimens in the Bio-
material for clinical use. In our study, because of the mechanical prop-
dentine and MTA groups are provided in Table 1. In the Biodentine
erties of Biodentine, this material received good rates for material
experimental group, the pulp responses were similar to those observed
handling and performance after restoration placement (3, 4,
in the MTA group (Fig. 1, Table 1). The dentin bridge was formed
22–26). Compared with Biodentine, MTA placement was more time-
directly underneath the capping materials at the injury site with both
consuming and technically difficult, although it is necessary to use
materials. Complete dentin bridge formation was observed in 6 teeth
a dental triturator for preparation of Biodentine. On the other hand,
in Biodentine and 7 teeth in the MTA groups (Fig. 1A, C, and E). In
MTA does not require any additional equipment.
most specimens in both groups, dentin was associated with an irregular
Formation of the dentinal bridge at the interface between the pulp
hard tissue, but occasionally the reparative tissue appeared heteroge-
and pulp-capping material is a controversial issue because it can be
neous with cell inclusions. The mean thicknesses of the hard-tissue
a sign of healing or a reaction to irritation (12, 16, 29). In the
dentin bridge in the Biodentine and MTA groups were 211.56 mm
present study, formation of the dentinal bridge was interpreted as
and 230.31 mm, respectively.
a positive reaction to stimulation and a sign of healing. Both materials
There was no evidence of inflammation, abscess, or necrosis
induced the formation of a dentinal bridge at its interface with the
below the dentinal bridge (Table 1). An absence of or few inflammatory
pulp tissue columnar cells, with polarized nuclei projecting into
cells and, rarely, dilated blood vessels were observed in a majority of
invaginations of the bridge observed in some specimens, which is
pulp specimens (Fig. 1). Minimal changes such as concentrated
clearly indicative of the formation of odontoblast cells and initiation of
collagen fibers and congested blood vessels were observed as the
tubular dentin (Fig. 1). Both calcium silicate cements induced an early
descent of chronic inflammation in 3 teeth in the Biodentine group
form of reparative dentin synthesis, probably because of modulation of
and 2 teeth in the MTA group.
pulp cell transforming growth factor–b1 secretion (3, 4, 26). Laurent
In most specimens in both groups, odontoblast and odontoblast-
et al (3) showed that particles of Biodentine were entrapped in the newly
like cells were discovered adjacent to the dentinal bridge with well-
formed foci, and mineralization appeared as osteodentin, suggesting that
distinguishable dentin tubules and with irregular pattern of tubules
material physicochemical properties might promote the mineralization
(Fig. 1B, D, and F). The layers of well-arranged odontoblast and
process as shown with MTA-based cements. Stimulation of cell prolifer-
odontoblast-like cells were found to form tubular dentin under the os-
ation and differentiation might be related to the tricalcium silicate itself,
teodentin.
which is one of the main components of Biodentine, and the presence of
Specimens in the control group exhibited normal pulp tissue with
both calcium and silicon ions (3, 4, 25–27). However, additional studies
palisade columnar odontoblast cells, a zone of Weil, a cell-rich zone,
are needed with immunohistochemistry and transmission electron
and central pulp with normal characteristics.
microscopy to assess the mode of action of Biodentine on the pulp.
Clinical criterion is inadequate for the long-term prognosis
TABLE 1. Summary of Different Categories of Histologic Features of Biodentine because critical evaluation of the results of pulp-capping materials
and MTA According to the Scores can only be made histologically (1, 16). Numerous investigations
Biodentine MTA have reported the successful application of MTA in pulp capping
(1, 2, 6, 10–16, 19, 26). In the present study, dentin bridge
1 2 3 4 1 2 3 4 formation was observed in all pulps capped with MTA as previously
Hard tissue bridge observed (2, 10, 16, 26). Researchers evaluated a combination of
Continuity 6 5 0 0 7 4 0 0 CaCl2 and MTA as a pulpotomy agent and described favorable results
Morphology 7 3 1 0 7 2 2 0 in calcified bridge formation (19), which was in accordance with the
Thickness 4 4 3 0 5 3 3 0
Evaluations of inflammatory response
results of the current investigation. However, Parirokh et al (1) re-
Type 8 3 0 0 9 2 0 0 ported that adding CaCl2 to MTA pulp-capping agent did not improve
Intensity 8 3 0 0 9 2 0 0 the properties of this biomaterial. In contrast to our study, histologic
Extension 8 2 1 0 9 1 1 0 results showed higher percentages of inflammation and necrosis and
Odontoblastic layer 2 6 3 0 2 7 2 0 a lower percentage of calcified bridge formation in MTA/CaCl2 samples
Presence of microorganisms 11 0 0 0 11 0 0 0
compared with MTA.

JOE — Volume 39, Number 6, June 2013 Human Pulp Response to Capping with Biodentine and MTA 745
Clinical Research

Figure 1. Human pulp capped with Biodentine (A, B, C, and D) and MTA (E and F). (A and C) The complete dentin bridge formation with Biodentine. Dentin
bridge incorporating dentin chips (*), (hematoxylin-eosin; original magnification, 50). (B and D) Higher magnification of (A and C). Observe hard bridge tissue,
new odontoblast cell layer, and dentinal tubules (arrow) (hematoxylin-eosin; original magnification, 400). (E) The complete dentin bridge formation with MTA.
(F) Higher magnification of (E). Observe hard bridge tissue, new odontoblast cell layer, and dentinal tubules (arrow) (hematoxylin-eosin; original magnification,
400). B, Biodentine; D, dentin; DB, dentin bridge; M, MTA; OL, odontoblast layer; P, pulp.

The new tricalcium silicate–based cement was tested in vivo in longevity of cavity restorations (31). In the present study, an absence
animals by Tran et al (26). This study evaluated the capacity of Bio- of bacteria in the stains may indicate that Biodentine and MTA have
dentine, MTA, and Ca(OH)2 to induce pulp healing in a rat pulp injury excellent sealing properties and prevent microleakage and pulpal
model. Similar to our study, the researchers observed formation of inflammation by providing a predictable secondary barrier under the
a dentin bridge at the injury site after 30 days that was secreted by cells surface seal. Moreover, all the cavities in our study were surface-
displaying an odontoblastic phenotype in all evaluated materials. These sealed with resin composite to prevent microbial leakage. The clinical
reparative structures that were induced by both calcium silicate cements trial evaluating the performance and safety of the new cement (22) re-
were homogenous and in continuity with primary dentin. In contrast, ported that Biodentine may be successfully used as a posterior restora-
the reparative tissue induced by calcium hydroxide had a porous orga- tion material for up to 6 months after direct pulp capping. After
nization, suggesting a reparative process different from those induced validation of pulp health, it may be partially removed to place a perma-
by calcium silicate cements. Similar to our observations, dentin tubules nent composite material (22, 23).
could be clearly observed, and the cells secreting this structure In our study the teeth had no inflammation process. Direct pulp
displayed odontoblastic characteristics (26). capping is used not only for accidental exposures of healthy pulps
Studies report that pulp response after direct capping is linked to but also for pulps challenged by caries or oral exposure after a traumatic
bacterial microleakage (6, 10, 12–15, 17). Microbes interfere with the injury. Therefore, the relevance of these studies conducted in healthy
pulpal response to capping materials (11, 30). It was noted that human teeth may be clinically limited, and further long-term assessment
bacteria stimulate pulpal inflammatory activity and reduce the area of is required to evaluate the pulp response to Biodentine in inflamed
dentin bridge formation irrespective of the material used for pulp pulp.
capping (31). Many authors have suggested that pulpal survival after
an oral exposure is not so much a function of an agent’s potential bioac- Conclusion
tivity but its capacity to protect the pulp from bacterial exposures (9, 11, Within the limitations of this study, Biodentine had a similar
12, 32–34). Prevention of bacterial leakage into cavity preparations is efficacy in the clinical setting and may be considered an interesting
an important objective in treatment planning and contributes to the alternative to MTA in pulp-capping treatment during vital pulp therapy.

746 Nowicka et al. JOE — Volume 39, Number 6, June 2013

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The authors deny any conflicts of interest related to this study. J Endod 2010;36:1778–81.
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JOE — Volume 39, Number 6, June 2013 Human Pulp Response to Capping with Biodentine and MTA 747