Original Reserach

Treatment of Deeply Carious Vital Primary Molars by

Complete Caries Removal Using Three Different Bioactive
Materials: A Pilot Study
Divya Gupta1, Shalini Garg2, Abhishek Dhindsa3, Neetu Jain4, Sarang Khajuria5, Anil Gupta6

A b s t r ac t
Aim: Present prospective clinical study compared success following the treatment of deep carious primary molars by complete caries excavation
(CCE) technique followed by indirect pulp capping (IPC) or direct pulp capping (DPC), as needed per case, with three different bioinductive
materials over 12 months.
Materials and methods: IPC or DPC was done on CCE in 45 molars of 31 children (mean age 5.74). Both the procedures were done with one of
the materials randomly assigned to group I: White mineral trioxide aggregate (MTA) (n = 15, 33.3%), group II: Biodentine (n = 16, 35.5%), and
group III: Dycal (n = 14, 31.2%). It was followed by restoration with resin-modified GIC and composite.
Results: Tooth was used as a unit of analysis. Twenty-seven children with 41 teeth could complete 12 months’ follow-up. DPC was done in 20%
of molars while IPC in 80% of molars. The success rate of CCE irrespective of the materials and in procedure pulpal exposure was 91.1%. MTA
showed 100% success, followed by Biodentine with 94 and 75% in the Dycal group.
Conclusion: CCE may be considered a definitive procedure in treating deeply carious primary molars when we use calcium silicate-based
materials, MTA or Biodentine, compared to Dycal in IPC and DPC procedures.
Clinical significance: Calcium silicate pulp capping may be a reliable option for treating deep carious primary molars, even in the cases of
pulpal exposure during the procedure.
Keywords: Bioactive materials, Biodentine, Deep caries, Direct pulp capping, Indirect pulp capping.
World Journal of Dentistry (2022): 10.5005/jp-journals-10015-2061

Introduction 1
Department of Paediatric and Preventive Dentistry, Institute of Dental
The primary goal of pulp therapy is to maintain the integrity and Sciences, Sehora, Jammu, India
health of teeth and their supporting tissues while maintaining pulp 2,6
Department of Pedodontics and Preventive Dentistry, Faculty of
vitality.1 Primary tooth until their natural exfoliation is required for Dental Sciences, SGT University, Gurugram, Delhi NCR, India
normal oral function and facial growth.2 Vital pulp therapy aims 3
Department of Paedodontics and preventive dentistry, Swami Devi
to preserve pulp viability by eliminating bacteria from the dentin- Dyal Hospital & Dental College, Barwala, Haryana, India
pulp complex and providing an environment ideal for tertiary 4
Department of Pediatric and Preventive Dentistry, Maharishi
dentin formation. 3,4 Markandeshwar College of Dental Sciences and Research, Ambala,
Carious treatment for deep lesion includes either complete Haryana, India
excavation that removes all the infected or affected carious dentin, 5
Department of Oral Medicine and Radiology, Institute of Dental
which impedes further cariogenic action with the inherent risk Sciences, Sehora, Jammu, India
of pulpal exposure, or incomplete excavation that seals carious Corresponding Author: Shalini Garg, Department of Pedodontics
dentin under an impervious restoration.5 In deep carious lesions, and Preventive Dentistry, Faculty of Dental Sciences, SGT University,
it is impossible to differentiate pathological soft dentin from Gurugram, Delhi NCR, India, Phone: +91 9215668621, e-mail:
physiological dentin adjacent to the pulp. What often appears to be [email protected]
an intact barrier of secondary dentin protecting the pulp may be a How to cite this article: Gupta D, Garg S, Dhindsa A, et al. Treatment
perforated mass of irregularly calcified and carious material.6 Partially of Deeply Carious Vital Primary Molars by Complete Caries Removal
excavated teeth might be at higher fracture risk, microleakage than Using Three Different Bioactive Materials: A Pilot Study. World
completely excavated teeth due to reduced bond strengths to J Dent 2022;13(4):382–388.
carious dentin. Source of support: Maharishi Markandeshwar (Deemed to be
Calcium hydroxide, since 1939 has been the gold standard for University), Mullana, Ambala
pulp capping. It forms a reparative dentine bridge through cellular Conflict of interest: None
differentiation, extracellular matrix secretion, and subsequent
mineralization.7 However, due to its disadvantages like internal
resorption, dissolution, adhesive property and poor seal, the use
of more predictable, promising, and biocompatible materials has Biodentine as alternatives for pulp therapy.8 Advancements of new
been warranted. Search for other suitable materials has shifted the biomaterials have caused a revolution in the old idea that DPC of
emphasis to newer calcium silicate-based materials like MTA and carious pulp exposure in a primary tooth is not recommended.9,10

© The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
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 Complete Caries Removal and Calcium Silicate Materials

Mineral trioxide aggregate and Biodentine (Septodont) offer I n c lu s i o n C r i t e r ia

benefits for DPC where layering of the exposed pulp surface with a
The teeth selected for inclusion in the study were required to
less cytotoxic material is essential to retain vitality and preserve its
meet the following criteria: primary molars with deep dentine
functional and biologic activities.11 These materials form a dentine
carious lesions according to clinical (ICDAS score of 5 or more) and
bridge directly underneath the capping materials, prompting
radiographic examinations (Ekstrand score of 3 or more); risk of pulp
mineralized foci formation from pulp cells and odontoblast like
exposure if completely excavated; no clinical and radiographic signs
cells adjacent to the dentinal bridge.12 These materials are known
and symptoms of irreversible pulpitis such as spontaneous pain/pain
as excellent biocompatible dental materials along with antibacterial
persisting after the disappearance of the existing stimulus/sensitivity
action. In pediatric dentistry, where isolation maintenance is
to pressure, free of abscess or fistula; no abnormal mobility;
challenging, the hydrophilic nature of calcium silicate cement and
radiographic evidence of an intact lamina dura; no radiographic
their outstanding sealing ability make them a suitable material. The
evidence of internal root resorption or inter-radicular or periapical
lack of research on complete excavation procedures followed by
pathosis; not expected to exfoliate within a year.
pulp capping in primary molars with new biomaterials has inspired
us to conduct this study. Our study was formulated to compare
the clinical and radiographic success of managing deep carious Procedure
primary molars by complete excavation and pulp capping with The complete standardized excavation was done under local
new bioactive types of cement-like Biodentine and MTA with the anesthesia to minimize the discomfort to the child under rubber
calcium hydroxide control. dam isolation. Central cariogenic biomass with necrotic and
demineralized dentine was removed with a goal of complete
M at e r ia l s and Methods excavation of carious lesion. Cavities were covered with either
white MTA or Biodentine or Calcium hydroxide cement (Dycal) in
This pilot randomized controlled clinical trial was conducted in
a 2–3 mm thickness, depending on the allocated group. In pinpoint
Maharishi Markandeshwar University, and ethical clearance was
pulpal exposure on complete excavation, light pressure was applied
given by the Institutional ethical committee (Project no. 491). The
with moist cotton pellets to control hemorrhage, followed by a
parents/guardians of the children were motivated for the treatment
gentle wash of normal saline (Figs 2A to F). Once hemostasis was
with a patient information form, and informed consent was taken.
obtained, the pulp was covered with capping material, adapted to
A study was performed on children reporting to the Department
walls, and scraped off the excess material. Resin-modified GIC was
of Pediatric and Preventive Dentistry in the age group of 3–9 years
used as a liner over pulp capping materials, and final restoration
with a deep carious lesion in primary molars.
was done with posterior composite, followed by a postoperative
radiograph (Fig. 3).
S amp l e D e s i g n All clinical parameters were assessed at an interval of 24 hours,
A total of 45 teeth were clinically and radiographically examined 1 month, 3 months, 6 months, and 12 months. Radiographic
and randomly distributed into three groups by chit method; group I: parameters were evaluated at 6 and 12 months. Immediate
White MTA, group II: Biodentine, Group III: Dycal (Control postoperative and follow-up IOPA radiographs were visualized
group) (Fig. 1). Intraoral periapical radiographs were taken with and assessed for dentine bridge formation (Figs 2 and 3),
cone paralleling technique after being standardized by using which was appraised by an increase in radio-opaque area by
radiograph positioners. two calibrated examiners. The study was single blinded for

Fig. 1: Flow diagram of randomized consort trial

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 Complete Caries Removal and Calcium Silicate Materials

Figs 2A to F: (A) Pinpoint pulp exposure after complete caries excavation;

(B) Yellow line depicting restoration extension, red line showing pulp Figs 3A to F: Indirect pulp capping (A, B) Preoperative and follow-up
chamber outline, Blue line showing an axial inclination of underlying radiograph of 75 Dycal; (C, D) Preoperative and follow-up radiograph
premolar; (C, D) Preoperative and direct pulp capping radiograph of 75 in of 64 MTA; (E, F) Preoperative and follow-up radiograph of 85 Biodentin
Biodentin group; (E, F) Preoperative and direct pulp capping radiograph
of 75 in Dycal group
post-op, 24 hours, 1 month, and 3 months. At 6 months, one (6.2%)
tooth reported sensitivity in Biodentine (p = 0.271) and one tooth
evaluators during radiographic evaluation (evaluators were (9.1%) in the Dycal group at 12 months (p = 0.271).
unaware about the radiograph belonged to which study group). Tenderness on percussion was reported in one tooth in the
Treatment success was determined by a combination of clinical Biodentine group at 6 months (also had pain and sensitivity and
and radiographic findings. Radiographic criteria for treatment was considered a failure). Mobility was seen in one tooth in the
success were: lack of periapical/inter-radicular pathology, Dycal group at six months (7.1%) (p = 0.271). Restoration loss was
lack of internal or external root resorption and intact lamina seen in three (21.4%) teeth at 6 months and one (9.1%) tooth at
dura. Clinical determinants of success included- lack of tooth 12 months in the Dycal group. Two (13.3%) teeth in the MTA group
mobility, no response to hot/cold/pressure stimuli, and lack of had restoration loss at 6 months and none in 12 months. One
pain associated with the treated tooth (spontaneous pain or (6.2%) tooth in the Biodentine group had a loss of restoration at
pain on percussion). 12 months. The difference was not statistically significant at 6 and
12 months, with p = 0.091 and 0.568, respectively. Loss of capping
material was seen only in the Dycal group at 6 and 12 months
R e s u lts (p = 0.271). The 100% success rate was achieved in the MTA group
All teeth were assessed for clinical parameters, that is, pain, followed by Biodentine and Dycal group (Table 1).
sensitivity, tenderness on percussion, swelling, mobility, and loss In the radiographic parameters (Table 2), furcation radiolucency
of capping material. Sixteen out of 45 teeth had preoperative pain; was present in the Biodentine and Dycal group in 1 tooth each at
on random distribution seven (50%) were allotted to Dycal group, 6 and 12 months. Widening of PDL was seen in the similar teeth in
three (20%) to MTA, and six (37.5%) to Biodentine group (p = 0.236). Biodentine and Dycal group at 6 months (p = 0.588). However, at
The pain was absent in all the teeth at postoperative, 24 hours 12 months, Dycal presented with one more tooth with widened
and 1 month. Two (16.6%) teeth in the Dycal group, one (6.2%) in PDL. Pathological root resorption was evident in one (6.7%) tooth
Biodentine, and none in MTA (0.0%) group had pain in the duration in MTA group, two teeth in Biodentine (12.5%) and Dycal (14.3%)
of the study (p = 0.271). A total of 13 teeth had sensitivity; four groups each at 6 months (p = 0.788). At 12 months, pathological
(28.6%) teeth in Dycal, four (26.7%) in MTA, and five teeth (31.3%) in resorption was not observed in any other teeth, irrespective of study
Biodentine group (p = 0.961). Sensitivity was absent in all the teeth at groups. One tooth in the Biodentine group showed a change in the

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 Complete Caries Removal and Calcium Silicate Materials

inclination of underlying Premolar at 6 months; also observed in follow up) in MTA, 15 (93.8%) teeth in Biodentine, and eight (66.7%)
the one (7.7%) tooth of MTA group. teeth in Dycal had dentine bridge formation (p = 0.025) (Table 4). At
Calcific degeneration was seen in one (7.2%) tooth of Dycal 6 months, better quality (++) was seen in MTA group in two (14.3%)
group (p = 0.322) at 6 months; one (6.3%) tooth in Biodentine and teeth (p = 0.273). Better quality (++) was seen in six (46.2%) teeth
three (23.1%) teeth in MTA group at 12 months. When the success in MTA, five (33.3%) in Biodentine, and none in Dycal at 12 months
of IPC (n = 36) and DPC (n = 9) was assessed, it was observed that (p = 0.079) (Table 5).
the total success rate was much higher for IPC (94.4%) compared
to DPC (77.8%). According to material used- MTA had 100% success
rate for both IPC and DPC; Biodentine had a 100% IPC success rate Discussion
and 75% for DPC; while 81.8% for IPC and 66.6% for DPC in Dycal The decision to whether completely excavate caries or leave the
group (Table 3). At 6 months, 31 teeth (68.9 %) and at 12 months diseased tissue under the restoration is still debatable, especially
36 (87.8 %) teeth had dentine bridge formation (p = 0.034). At in pediatric patients. Massler, 1972 documented that the most
6 months, 14 (92.9%) teeth in MTA, 13 (81.3%) in Biodentine, and critical cause of vital pulp therapy failure is bacterial contamination
four (28.6%) teeth in Dycal group had dentine bridge formation and suggested coronal seal is a critical factor in vital pulp
(p = 0.003). At 12 months, all 13 (100%) teeth (which turned up for therapy.13 Failure rate of composite restoration is always high after

Table 1: Comparison of the success rate in different groups at 12 months

MTA 13 13 0 100%
Biodentine 16 15 1 93.8%
Dycal 12 9 3 75% 0.090^
^Denotes not significant using Chi-square

Table 2: Presence of radiographic changes according to materials at 6 months and 12 months

Deviated axial
Furcation Widening of Pathological inclination of Postoperative Calcific
radiolucency PDL root resorption underlying tooth caries degeneration
MTA 0 0 1 0 0 0
(n = 15) (6.7%)
Biodentine 1 1 2 1 0 0
(n = 16) (6.3%) (6.3%) (12.5%) (6.3%)
Dycal 1 1 2 0 2 1
6 months (n = 14) (7.1%) (7.1%) (14.3%) (14.3%) (7.1%)
Total 2 2 5 1 2 1
(N = 45) (4.4%) (4.4%) (11.1%) (2.2%) (4.4%) (2.2%)
p-value 0.588 0.588 0.788 0.395 0.98 0.322
MTA (n = 13) 0 0 0 1 0 3
(7.7%) (23.1%)
Biodentine (n = 16) 1 1 2 2 0 1
(6.3%) (6.3%) (12.5%) (12.5%) (6.3%)
Dycal (n = 12) 1 2 1 0 1 0
12 months (8.3%) (16.7%) (8.4%) (8.4%)
Total 2 3 3 3 1 4
(N = 41) (4.9%) (7.3%) (7.3%) (7.3%) (2.4%) (9.8%)
p-value 0.594 0.272 0.432 0.453 0.298 0.126

Table 3: Comparison of success of IPC and DPC according to the materials

IPC DPC
Total cases = 45 (N = 36) (N = 9)
n MTA Biodentine Dycal MTA Biodentine Dycal
13 12 11 2 4 3
Success 13 12 9 2 3 2
% 100% 100% 81.8% 100% 75% 66.6%
Total success rate 94.4% 77.8%
p-value* 0.0903 0.67
*Using Chi-square test

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 Complete Caries Removal and Calcium Silicate Materials

Table 4: Comparison of dentine bridge formed at 6 and 12 months in different groups

Groups Total
Dentine bridge MTA (15) Biodentine (16) Dycal 14) (45) p-value
6 months Absent Count 1 3 10 14 0.003*
% within gp 7.1 % 18.7% 71.4% 31.1%
Present Count 14 13 4 31
% within gp 92.9% 81.3% 28.6% 68.9%
MTA (13) Biodentine (16) Dycal (12) Total (41)
12 months Absent Count 0 1 4 5 0.025*
% within gp 0 6.2% 33.3% 12.2%
Present Count 13 15 8 36
% within gp 100% 93.8% 66.7% 87.8%
*Denotes significant using Chi-square

Table 5: Comparison of thickness of dentine bridge formed at 6 and12 months in different groups
Groups
Dentine bridge MTA (15) Biodentine (16) Dycal (14) Total (45) p-value
6 months + Count 12 13 4 29 0.273^
% within gp 85.7% 100% 100% 93.5%
++ Count 2 0 0 2
% within gp 14.3% 0.0% 0.0% 6.5%
Total Count 14 13 4 31
% 45.2% 41.9% 12.9% 100%
MTA (13) Biodentine (16)
^Denotes not significant using Chi-square

selective caries removal compared to complete caries removal. The In the present study, 3–9 year age group was selected as
inference is per the findings of the study which when compared maintenance of the vitality of primary molars is crucial during this
the efficacy of three techniques for caries removal- complete caries period of dental chronology till their exfoliation. This also allowed us
removal (CCR), selective caries removal (SCR), and stepwise caries to evaluate the procedure’s success as root resorption does not start
removal (SWR)— in deeply carious vital primary teeth and found less until 7–8 years of age.18 According to Ekstrand classification, a deeply
composite restorative failure in CCR group.14 The changing concepts carious molar with an ICDAS score of 5 or more and a radiographic
and philosophies of carious tooth management have challenged score of 3 or more was considered a unit for complete excavation
whether or not the softened dentin should be removed before and randomly allotted to experimental groups (MTA; Biodentin;
the restoration.15 Various studies are in the support of incomplete Dycal). The combination of ICDAS and radiographic method has
caries excavation over complete excavation. However, the success been proved as one of the best performing tools for detecting
of restorative treatment depends upon the complete elimination of dentine caries (Ekstrand KR et al., Rodrigues JA et al.).19,20 CCE was
bacteria or caries, and it is still considered as the best conservative done without exposing the pulp; however, teeth where mechanical
treatment; irrespective of the restorative material used.16 pulp exposure occurred, were also retained in the study, and
Dental Pulp has a well-established capacity to form restored accordingly. A total of 45 teeth were included in the study
rigid tissue barriers called reparative dentin following pulp and assessed based on clinical and radiographic parameters. Four
capping.17 Biomaterials should initiate the dentin bridge formation patients were lost to follow-up, and nine (20%) teeth had pulpal
with minimum or no pulp inflammation and should restore the exposures while excavation and DPC were performed.
normal pulp tissue function. It has been documented those Since each tooth was randomly allotted to a particular group
materials containing calcium ions and high pH promote complex before starting the excavation, there was an uneven distribution
tissue formation. Different materials have been advocated for using of DPC cases (two in MTA, four in Biodentine, three in Dycal).
pulp capping agents in the literature, that is, MTA, Biodentine, All the parameters were compared on variables like material
calcium hydroxide (Dycal), propolis, nano hydroxyapatite, used, a procedure performed (IPC/DPC), and jaw involved
enamel matrix derivative, and many more. Recent advances in (maxillary/mandibular). A total of 16 teeth had mild pain initially
bioactive dentin substitute materials have opened newer vistas on chewing and got relief postoperatively (food lodgment,
in healing wounded dental pulp by ensuring consistent dentin pressure could be the predictable pain cause). Two (16.6%) teeth
bridge formation. in the Dycal (DPC) and one tooth (6.2%) in the Biodentine group

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 Complete Caries Removal and Calcium Silicate Materials

(IPC) reported pain, and in those failures, nonvital pulp therapy fear of exposing the pulp? Dhar et al. also found similar success
was done. Relief from the pain in most of the cases depicts among the two therapies and suggested that the choice of pulp
the effectiveness and efficiency of complete excavation as a therapy in deeply carious vital primary teeth should depend on
management tool in subjective symptoms in deep carious lesions a biological approach for removal of caries affected dentine pulp
in primary molars.13 teeth initially had sensitivity to cold, which exposures and clinical expertise. 30
resolved post-treatment. One tooth in the Biodentine and Dycal
group reported sensitivity (same teeth also had pain and were
considered failures). The reduction in the number of postoperative C o n c lu s i o n
hypersensitivity cases in the present study might be because the MTA and Biodentine appear to be better pulp capping materials
pulp is protected from dentinal fluid flow in the tubules by the than Dycal in IPC/DPC procedures. Both MTA and Biodentine form
low-permeability zone is deeply infected dentin.10 dentine bridge relatively faster, as observed in 6 months than Dycal.
One tooth had mobility in the Dycal group at 12 months, in which Complete excavation before doing pulp capping may be considered
pathological resorption was evident radiographically. Radiographic a definitive procedure in treating deeply carious primary molars
evaluation at six months showed Furcation radiolucency and to maintain the arch’s vitality and integrity. Therefore, it can be
Widening of PDL in two teeth (one each in Biodentine and Dycal concluded that management of deep carious lesion with complete
group). Pathological root resorption was seen in one tooth in MTA excavation procedure when done in collaboration with recently
and two teeth each in Biodentine and Dycal group at 6 months; advanced biocompatible pulp-capping materials like MTA and
while pathological resorption was not evident in any other tooth Biodentine leads to a more predictable and successful outcome
at 12 months. Comparison of dentine bridge formation in different irrespective of the fact whether it is directly or indirectly capped but
material groups showed statistically significant differences at 6 and with required coronal seal. A continuation of this study with larger
12 months (p = 0.003 and 0.025). More teeth in the MTA group sample size and longer follow-up time is advised to overcome the
showed dentine bridge formation than the Dycal group at 6 and study’s limitations.
12 months (p = 0.003 and 0.078). Bogen G concluded that vital pulp
therapy using MTA is a treatment option for teeth diagnosed with
a condition no more severe than reversible pulpitis.9 According to References
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388 World Journal of Dentistry, Volume 13 Issue 4 (July–August 2022)