Dental Materials Journal 2017; 36(1): 1–7

Review

Cytotoxicity and biocompatibility of resin-free and resin-modified direct pulp

capping materials: A state-of-the-art review
Liang CHEN and Byoung In SUH

Department of Research and Development, Bisco Inc., 1100 W Irving Park Road, Schaumburg, IL, 60193, USA
Corresponding author, Liang CHEN; E-mail: lchen@bisco.com, lchenchem@yahoo.com

Direct pulp capping is the placement of a dental material directly over exposed pulp to prevent dental pulp from dying and avoid
the need for root canal treatments. Calcium hydroxide and calcium silicates/mineral trioxide aggregates (MTA) have been commonly
used for direct pulp capping with great success clinically. In recent years, resin-modified calcium hydroxide and calcium silicates have
been developed with the advantages of precise placement, command set, and superior physical strength. As pulp capping materials
would be in direct contact with the pulp, the cytotoxicity and biocompatibility is of particular importance in order to avoid pulp
irritation and maintain pulp vitality. Therefore, this review article will summarize the cytotoxicity and biocompatibility of direct pulp
capping materials, particularly resin-modified materials.

Keywords: Cytotoxicity, Pulp capping, Calcium hydroxide, MTA, Calcium silicates

strength, better handling, easier to use and more

INTRODUCTION
Pulp exposures may result from caries removal during
restorations, large caries, or trauma such as a sports
injury. A pulp exposure could cause inflammation of the
dental pulp (pulpitis), which may become irreversible,
causing pain, pulp necrosis, and eventually may require
an extraction or root canal treatment1). Clinically, the
treatment of a pulp exposure includes a direct pulp
capping or pulpotomy. A direct pulp capping is the
placement of a dental material directly over an exposed
pulp, to protect the dental pulp and preserve its vitality;
a pulpotomy involves the removal of a portion of the pulp
before the placement of a material. The goal of direct
pulp-capping is to prevent the dental pulp from dying
and avoid the need for a root canal treatment.
A number of materials, such as zinc oxide eugenol,
glass ionomer/resin-modified glass ionomer, and
adhesive systems, have been used in direct pulp capping,
but they normally have poor clinical outcomes due to the
cytotoxicity to the dental pulp2). Calcium hydroxide has
a long track record of clinical success, and is considered
the “gold standard” of direct pulp capping materials2). In
recent years, calcium silicates, such as mineral trioxide
aggregates (MTA) have generated great interest as direct
pulp capping materials. MTA is suggested to be superior
to calcium hydroxide and could be “a more predictable
pulp capping material than calcium hydroxide”3).
Although both calcium hydroxide and MTA have been
well accepted clinically, they both have some
disadvantages, including long-setting times (or lack of
setting), poor handling, weak physical strength, high
solubility, and/or gradual resorption. Resin-modified
calcium hydroxide and calcium silicates/MTA have
been recently developed with the aim of improving
the materials. They can be immediately light cured,
providing advantages including stronger mechanical
precise placement. Although some resins released
from dental restorations may be cytotoxic in sufficient
concentrations4), resin-based materials, which are not in
direct contact with dental pulp have been successfully
used in dental restorations for several decades. As pulp
capping materials would be in direct contact with pulp,
the cytotoxicity and biocompatibility is of particular
importance in order to avoid pulp irritation and
maintain pulp vitality. The purpose of this review article
is to summarize the cytotoxicity and biocompatibility
of direct pulp capping materials, particularly resin-
modified materials.
CALCIUM HYDROXIDE AND RESIN-MODIFIED
CALCIUM HYDROXIDE
Calcium hydroxide was introduced in dentistry in
1920s, and has been used with great clinical success
as a direct pulp capping material for several decades2).
Calcium hydroxide is a strong base with a high pH of
approximately 12. It is slightly soluble in water, releasing
Ca2+ and OH− ions through the ionic dissociation5). The
high pH of OH− ion provides excellent antibacterial
properties, minimizing bacterial penetration to the
pulp2). On the other hand, the high pH causes irritation
of the pulp tissue and develops a superficial three-layer
necrosis on exposed pulp, stimulating and forming
mineralization directly against the necrotic zone6,7). The
Ca2+ ion provides a source of calcium for initiating and
stimulating mineralization6,7). Three types of calcium
hydroxides have been used for direct pulp capping,
including one-paste non-setting calcium hydroxide, two-
paste self-setting calcium hydroxide, and resin-modified
calcium hydroxide.
Historically, calcium hydroxide was used in a
powder form directly on exposed pulp. Currently,

Received Mar 22, 2016: Accepted Jul 11, 2016

doi:10.4012/dmj.2016-107 JOI JST.JSTAGE/dmj/2016-107
2 Dent Mater J 2017; 36(1): 1–7

pre-mixed calcium hydroxide pastes (one-paste non-
setting system) are commercially available, such as
Calcicur (Voco, Cuxhaven, Germany) and UltraCal XS
(Ultradent Products, South Jordan, UT, USA) (Table 1).
These products may also contain a radiopacifier, such as
barium sulfate. The major disadvantages of one-paste
calcium hydroxide systems include: lack of setting, weak
physical properties, gradual resorption/dissolution, and
the so-called “tunnel effects” (the porosities in the newly
formed dentin)1). Although calcium hydroxide has been
widely accepted in clinical practice, studies have shown
it may be cytotoxic due to high alkalinity. It was reported
that Calcicur (21% cell vitality in 3-day MTT test) was
more cytotoxic than MTA or the negative control (26–
35% cell vitality in the same test)8). Another study using
rat subcutaneous tissue showed that calcium hydroxide,
such as UltraCal XS, caused an intense inflammatory
reaction and a coagulative necrosis at 7 days, but the
inflammatory process was significantly reduced at 30
days9). This study also showed that different solvents
used to make calcium hydroxide pastes (water or
polyethylene glycol), or different radiopacifiers (barium
sulfate, barium oxide, or zinc oxide) did not interfere in
their tissue reaction9). The clinical success rate of calcium
hydroxide pastes for direct pulp capping over a 10-year
period of time was reported to be 59.0% (59 teeth total).
The failures included subsequent root canal treatment
(15 teeth), pulp necrosis (1 tooth), asymptomatic apical
periodontitis (2 teeth), clinical signs and symptoms (1
tooth), and extractions (5 teeth)10). Another clinical study
showed that the success rate of direct pulp capping of
1,075 permanent teeth with calcium hydroxide was 80.1,

Table 1 Compositions of representative direct pulp-capping materials

Material Type Materials Compositions Manufacturer

Ultradent Products,
One-paste UltraCal XS Calcium hydroxide, water, barium sulfate South Jordan,
non-setting UT, USA
calcium
hydroxide Calcium hydroxide, water, cellulose derivatives Voco, Cuxhaven,
Calcicur
and barium sulfate Germany

Base paste: calcium phosphate, calcium tungstate, zinc

Dentsply
oxide, iron oxide pigments, 1,3-butylene glycol disalicylate
Tulsa Dental,
Dycal Catalyst paste: calcium hydroxide, zinc oxide,
Johnson City,
Two-paste zinc stearate, titanium oxide, iron oxide pigments,
TN, USA
self-setting N-ethyl-o/p-toluene sulphonamide
calcium
hydroxide Base paste: calcium hydroxide, zinc oxide, calcium oxide,
zinc stearate, N-ethyl-o(or p)-toluenesulphonamide Kerr, Orange,
Life
Catalyst paste: titanium dioxide, barium sulfate, methyl CA, USA
salicylate

Prisma VLC Dentsply

Calcium hydroxide, barium sulfate, UDMA, TEGDMA
Dycal Tulsa Dental
Resin-modified
calcium Ultra-Blend Calcium hydroxide, tricalcium phosphate, diurethane
Ultradent Products
hydroxide Plus dimethacrylate, TEGDMA

Calcimol LC Calcium hydroxide, fumed silica, UDMA, TEGDMA Voco

Dentsply
ProRoot MTA Portland cement, bismuth oxide
Tulsa Dental

Tricalcium silicate, dicalcium silicate, tricalcium aluminate, Angelus, Londrina,

MTA-Angelus
Calcium tetracalcium aluminoferrite, bismuth oxide PR, Brazil
silicates/MTA
Powder: tricalcium silicate, calcium carbonate
Septodont,
and zirconium oxide
Biodentine Saint-Maurdes-
Liquid: water, calcium chloride (accelerator)
Fosses, France
and modified polycarboxylate

Resin-modified Portland cement (calcium silicates), fumed silica, Bisco, Schamburg,

TheraCal LC
calcium silicates Bis-GMA, polyglycol dimethacrylate IL, USA

TEGDMA: Triethylene glycol dimethacrylate; Bis-GMA: bisphenol A diglycidyl methacrylate; UDMA: urethane
dimethacrylate
 Dent Mater J 2017; 36(1): 1–7
68.0 and 58.7% after 1, 5 and 9 years, respectively11).
Because of the disadvantages of high solubility
and the lack of setting of one-paste calcium hydroxide
systems, a curable two-paste calcium hydroxide system
has been developed and widely used in clinical practice.
Commercial products include Dycal (Dentsply Tulsa
Dental, Johnson City, TN, USA) and Life (Kerr, Orange,
CA, USA) (Table 1). Two-paste calcium hydroxide
systems normally contain a base paste and catalyst paste.
One of the pastes contains active ingredient calcium
hydroxide, and the other paste contains disalicylate. The
setting reaction occurs between the calcium hydroxide
and disalicylate, forming calcium disalicylate. Two-
paste calcium hydroxide system may also contain
other components, such as zinc oxide (a reactant, but
not a principle reactant), zinc stearate (accelerator),
radiopacifier (calcium tungstate, or barium sulfate etc.),
pigments, plasticizer and/or oil (to make a paste form),
and/or an antibacterial agent. The setting time for a two-
paste calcium hydroxide system is normally 2–6 min.
The physical strengths, such as compressive strength,
tensile strength, and modulus of elasticity, are usually
low. Although two-paste calcium hydroxide systems
have setting characteristics, they are still soluble and
could dissolve over time12). Two-paste calcium hydroxide
systems have been shown to be more toxic than the non-
setting one-paste calcium hydroxide systems, possibly
due to the added toxicity of the additional components
such as disalicylate, accelerator, and/or plasticizer. For
example, in a 3-day MTT assay test with odontoblasts
cells, two-paste calcium hydroxide (Dycal) demonstrated
the lower cell vitality rate than other types of direct
pulp capping materials, such as one-paste calcium
hydroxide and MTA8). Dycal also showed significantly
greater toxicity to human dental pulp cells than resin
composites13). It was reported that the toxicity of the
two-paste calcium hydroxide system was not able to be
altered by six different growth factors (bone morphogenic
peptide-2 and 7, fibroblast growth factor-2, epidermal
growth factor, transforming growth factor-β, and insulin-
like growth factor-I) which have been shown to alter
pulp cell growth or differentiation. In contrast, some of
the specific growth factors can make pulp cells resistant
to the toxicity of composite materials13). The success
rate for Dycal in direct pulp capping was reported to be
73% (15 cases) after 6-month follow-up14). The success
rates for another two-paste calcium hydroxide (Life,
Kerr) after 3-year direct pulp capping were reported as
92.2% with mechanical exposure and 33.3% with carious
exposure15). In another clinical study, the success rate
for Life in 132 pulp caps was 37% (18% questionable and
45% failure) in the 5-year group and 13% (80% failing
and 7% questionable) in the 10-year group16).
Light-curable resin-modified calcium hydroxide
materials, such as Prisma VLC Dycal (Dentsply Tulsa
Dental), Calcimol LC (Voco), and Ultra-Blend Plus
(Ultradent Products) (Table 1) have been used for direct
pulp-capping. Compared to the conventional one-paste
or two-paste calcium hydroxide systems, the resin-
modified version has several advantages, including light-
3
polymerization, superior physical properties, minimally
affected by phosphoric acid, and low water solubility/does
not dissolve over time. It is known that un-polymerized
resins/monomers are toxic to pulp cells17). For example,
it was reported that Calcimol LC presented the higher
cytotoxicity to MDPC-23 cells than the resin-free non-
setting calcium hydroxide paste Calcicur, but it showed
similar or lower cytotoxicity than two-paste self-setting
calcium hydroxide Dycal (vitality with MTT test after 72
h: Calcicur 21%, Calcimol LC 15%, Dycal 9%; number
of vital cells with Alamar blue tests after 72 h: Calcicur
262000, Calcimol LC 33000, Dycal 30000). However,
the composite resin presented mild to no toxic effects to
the odontoblast-like MDPC-23 cells, as long as it was
polymerized18). A study showed resin-modified calcium
hydroxide VLC Dycal was not more cytotoxic than the
control calcium hydroxide. When VLC Dycal was cured
sufficiently with a longer curing time, the cytotocixity of
the resin in VLC Dycal disappeared. At the same time,
OH− was released and started to cause cytotoxicity19). An
in vitro study indicated that Ultra-Blend Plus had no
increase of adult human dermal fibroblast cytotoxicity
levels, compared to negative control20). It is worth to note
that a typical 70% of polymerization degree of conversion
of dimethacrylate monomers does not mean 30% of
free monomers. It means 30% of methacrylate groups
are still available for polymerization, but among those
30%, most of them are already in the polymer matrix.
Approximately, only 9% of monomers are free monomers
(i.e. both methacrylate groups in one monomer are un-
cured), and most of that 9% free monomers are located
inside the polymer matrix (would not leach out).
CALCIUM SILICATES AND RESIN-MODIFIED
CALCIUM SILICATES
Mineral trioxide aggregates (MTA), such as ProRoot
MTA (Dentsply Tulsa Dental) has been widely used as a
direct pulp capping material (Table 1). MTA is a mixture
of tricalcium silicate, dicalcium silicate, and tricalcium
aluminate. Bismuth oxide (roughly 20%) is also included
in MTA for radiopacity. Because of the success of MTA,
new versions of calcium silicate-based materials (such as
Biodentine (Septodont, Saint-Maurdes-Fosses, France))
have also been developed (Table 1). The mechanism
of action of MTA/calcium silicatse is similar to that of
calcium hydroxides. Calcium hydroxide is the by-product
of the primary reaction (hydration) of MTA/calcium
silicates with water. The hydration slowly results in a
gel which solidifies after several hours. MTA/calcium
silicates are believed to have better sealing ability,
biocompatibility and higher physical strength than
calcium hydroxide1,21). For instance, the compressive
strength of Biodentine (calcium silicates) was reported
to be 49 MPa after 7 days, while Dycal (two-paste self-
setting calcium hydroxide) was only 16 MPa21). Compared
to calcium hydroxide, MTA/calcium silicates produce
more uniform and thicker dentin bridge formations with
less inflammatory response and less necrosis of pulp
tissue22,23), possibly due to its ability to increase bone
4 Dent Mater J 2017; 36(1): 1–7
morphogenetic protein (BMP-2 protein) production24)
and induce reparative dentinogenesis25).
Many studies have demonstrated that MTA/calcium
silicates were less toxic than calcium hydroxides. In
one study, MTA exhibited no cytotoxicity to rat dental
pulp cells after 72 h, whereas the two-paste calcium
hydroxide (Dycal) killed almost all cells24). Another
study also suggested that calcium silicates (ProRoot
MTA, MTA-Angelus (Angelus, Londrina, PR, Brazil),
Biodentine) were less cytotoxic to odontoblasts cells
than two-paste calcium hydroxide (Dycal) and one-paste
calcium hydroxide (Calcicur)8). An in vitro adult human
dermal fibroblast cytotoxicity study showed that MTA
materials (MTA-Angelus, Brasseler Endosequence Root
Repair Putty) and resin-modified Ca(OH)2 (Ultra-Blend
Plus) had cytotoxicity levels statistically similar to the
negative control, which was statistically less cytotoxic
than the two-paste calcium hydroxide (Dycal)20). MTA
also showed less toxic to human tooth germ stem cells
than Dycal26). An in vivo study (60 days) with dogs
showed that none or mild inflammatory response
occurred beneath the pulpal wound capped with calcium
hydroxide saline paste or Pro-Root MTA. MTA and
calcium hydroxide presented no statistical difference
in terms of the pulpal response, but the teeth capped
with calcium hydroxide had greater healthy pulp loss27).
One study compared MTA (ProRoot) with two-paste
calcium hydroxide system (Dycal) when used as pulp-
capping materials in 11 pairs of human teeth. After
1 week, 2, 3, 4, and 6 months, MTA groups presented
less inflammation, less hyperaemia, less necrosis, more
frequent odontoblastic layer formation, and thicker
dentinal bridging (0.19–0.43 mm for ProRoot, and
0.02–0.15 mm for Dycal from 3–6 months) than the
calcium hydroxide group23). Another in vivo study also
demonstrated that MTA caused less inflammation,
less necrosis, and faster dentin bridge formation, than
calcium hydroxide Dycal28). An in vitro study from the
same paper demonstrated that calcium hydroxide
(29.4% decrease of cell metabolic activity) caused
higher cytotoxic effects to the MDPC-23 cells than MTA
(9.9% decrease)27). The success rate of MTA (ProRoot)
for direct pulp capping was reported to be 80.3% (195
cases) after 2 year-recall, which was higher than that
of calcium hydroxide (Life, Kerr) (68.5%, 181 cases)29).
Another clinical trial showed the overall success rate
for MTA (ProRoot) was 80.5% (170 teeth total), with
33 failed teeth (19.5%) in 10 years10). The success rate
was higher than that of calcium hydroxide (59%). The
failure included subsequent root canal treatment (25
teeth), pulp necrosis (2 teeth), asymptomatic apical
periodontitis (4 teeth), and extraction (2 teeth)10). In
another paper, 98% of teeth (49 teeth total) capped
with MTA received favorable outcomes on the basis of
radiographic appearance, subjective symptoms, and cold
testing, over an observation period of nine years3).
Similar to resin-modified calcium hydroxides,
light-curable resin-modified calcium-silicate based
materials (such as TheraCal LC, Bisco, Schaumburg,
IL, USA) have been developed and used for direct pulp
capping. Compared to conventional calcium silicates/
MTA materials, the resin-modified version has several
advantages, including immediate light-polymerization,
preventing wash out of material, and superior physical
properties30). One study showed that TheraCal LC
presented higher calcium release than MTA (ProRoot)
and calcium hydroxide (Dycal) throughout a 28-day test
period, while its solubility was significantly lower31).
The pH profile of the medium conditioned by TheraCal
LC was similar as that of ProRoot MTA (from 11 to
8) during the 28-day test31). Similar to other types of
calcium hydroxides or calcium silicates materials (Dycal,
Calcicur, Calcimol LC, MTA Angelus, and Biodentine),
TheraCal LC exhibited valuable antibacterial activity32).
It was reported that TheraCal LC stimulated apatite
formation after 24 h immersion in Dulbecco’s Phosphate
Buffered Saline (DPBS) solution33). It is worth noting
that there is a major difference between TheraCal LC
and resin-modified calcium hydroxide (such as Calcimol
LC, VLC Dycal, and Ultra-Blend Plus). TheraCal
LC contains a hydrophilic monomer/polymer matrix,
while Calcimol LC, VLC Dycal, and Ultra-Blend Plus
contain a hydrophobic monomer/polymer matrix. The
hydrophilic matrix allows higher calcium and hydroxide
release, which are very important in protecting pulp
their ability to stimulate dentin formation and provide
antibacterial action (high alkalinity), respectively6,31,33).
Both TheraCal LC and resin-modified calcium hydroxide
were shown to be more cytotoxic to murine odontoblasts
cells and human dental pulp stem cells than resin-free
calcium silicates, such as Biodentine, MTA Angelus,
and ProRoot MTA, but they showed similar or lower
cytotoxicity than Dycal (vitality with MTT test after 72
h: resin-modified materials: 14–15%, resin-free MTA
28–35%, Dycal 9%; number of vital cells with Alamar
blue tests after 72 h: resin-modified materials: 33000–
35000, resin-free MTA 333000–533000, Dycal 30000)8,34).
However, this cytotoxicity might be due to the uncured
monomers in the oxygen inhibition layer on the surface
of TheraCal LC test samples during sample preparation
in the laboratory (exposure to air/oxygen). Research
studies suggested that uncured monomers/resins were
toxic to pulp cells, while cured resins presented no
toxic effects17,18). However, it is worth noting that an
oxygen inhibition layer is not clinically relevant, since
the pulp capping materials are placed inside teeth
with no oxygen present. It would be more clinically
relevant to remove the oxygen inhibition layer prior to
cytotoxicity tests. Covering the materials with a Mylar
strip may reduce the oxygen inhibition layer, but it does
not completely remove it. A rinse of the surface with
ethanol or acetone may remove the oxygen inhibition
layer. A 14-day in vivo study with rats indicated that
the tissue responses and temporospatial localization
of dentin matrix protein 1 and osteopontin in pulps
capped with TheraCal LC were similar to those capped
with calcium hydroxide or ProRoot MTA35). Compared
to the resin-containing calcium hydroxide (Ultra-Blend
Plus) and resin-modified Glass Ionomer (Vitrebond, 3M,
ESPE), the resin-containing calcium silicates (TheraCal
 Dent Mater J 2017; 36(1): 1–7
LC) presented lower cytopathic effects to cultured pulp
cells36). In a 4-week in vivo study on primate pulp capped
with 4 different materials, both the Portland cement
and TheraCal LC groups presented more frequent and
thicker hard tissue bridge formation than the GIC and
VLC Dycal groups37). A 2-year in vivo study demonstrated
that TheraCal LC had higher success rate (93.3%) for
direct pulp capping than antibacterial adhesive system
(Protect Bond, Kuraray) (83.3%) and Glass Ionomer
cement (Fuji IX, GC) (66.6%)38). Another clinical study
indicated that the success rate for TheraCal LC was not
significantly different from that for Dycal (~70% in 15
cases) in direct pulp capping after 6-month follow-up14).
The success rate went up to 100% with a pre-treatment
of laser irradiation to the exposed pulp14).
Calcium silicates/MTA-based materials and
Portland cements contain trace amount of heavy
metals, such as lead (Pb), arsenic (As), cadmium (Cd),
nickel (Ni), iron (Fe), copper (Cu), manganese (Mn),
and zinc (Zn)39). It was reported that the MTA/Portland
cements materials, such as CPM (Egeo, Buenos Aires,
Argentina), CPM Sealer (Egeo), Gray MTA-Angelus
(Angelus), ProRoot-MTA (Dentsply Tulsa Dental), and
Gray Portland cement (Votorantim Cimentos, Cubatão,
SP, Brazil) contained arsenic levels higher than the
ISO-recommended limit for water-based cements of 2
mg arsenic/kg material (ISO 9917-1 standard). Only
White Portland cement (Cimento Rio Branco, Rio de
Janeiro, RJ, Brazil), MTA-Obtura (Angelus) and White
MTA-Angelus (Angelus) presented arsenic levels below
the limit set in the ISO standard40). Other studies
demonstrated that MTA-based materials, such as
ProRoot, MTA-Angelus, and/or Biodentine, contained
low level of arsenic41-43), aluminium44), beryllium44),
cadmium44), chromium43,44) iron44), and lead42,43). During
the long setting periods of MTA/calcium silicates, toxic
chemicals could leach out, causing cytotoxicity. It was
reported that a calcium phosphate silicate-based sealer
(EndoSequence BC Sealer, Brasseler, Savannah,
GA, USA) required 168 h to reach the final set, and it
exhibited severe cytotoxicity at 24 h, which gradually
decreased to moderate cytotoxicity over the 6-week
period45). Other evidence was shown that low levels of
heavy metals like chromium, arsenic and lead leached
out from the solid MTA-based materials, such as
ProRoot and MTA-Angelus in water and simulated body
fluid41,46). It is important to note that “the dose makes
the poison”. In the other words, all substances could be
poisonous, depending upon dosage47). The low levels of
concentration were believed to be safe for use in clinical
practice41,43). An in vivo study using rats compared the
release of heavy metal (aluminium) from three different
type of calcium silicate-based materials: MTA Angelus,
MTA Fillapex (containing MTA, salicylate resin, natural
resin, bismuth oxide, and silica), and resin-containing
TheraCal LC. After 6, 30, and 60 days of restorations
with these materials, the levels of aluminium (Al) in
the plasma in which MTA Angelus (322–529 ppb) and
MTA Fillapex (299–468 ppb) were implanted, were
around twice as high as Theracal LC (143–226 ppb)
5
and the control (102–155 ppb) groups39). It is likely that
TheraCal LC released less Al because of its lower
solubility31) and shorter setting time (immediately light-
cured) which reduces the chance of Al-release prior to
the setting of the material39).
OTHER MATERIALS FOR PULP-CAPPING
Several other types of materials have been reported
as direct pulp-capping materials, including zinc oxide
eugenol (ZOE), glass ionomer/resin-modified glass
ionomer (GI/RMGI), and adhesive systems. Similar
to calcium hydroxide and calcium silicates, ZOE has
bactericidal effects. However, ZOE releases sufficient
amounts of eugenol to be highly cytotoxic. A study
showed ZOE causes chronic inflammation, with no pulp
healing and no dentin bridge formation after 12-weeks
direct pulp-capping, while calcium hydroxide showed
pulpal healing2). ZOE is not recommended for direct pulp
capping.
GI/RMGIs are less cytotoxic than ZOE. In addition,
they are able to chemically bond to teeth. However,
unlike calcium hydroxide/calcium silicates, GI/RMGIs
are acidic and lack anti-bacterial effects. This initial
acidity of GI/RMGI with a prolonged period at low pH,
in addition to cytotoxicity of other components, may
cause damaging effects on the pulp48). It was reported
that direct pulp-capping with RMGI showed chronic
inflammation and no dentin bridge formation after 10
months of restoration, while calcium hydroxide showed
significantly better pulpal healing2). GI/RMGIs should
not be used for direct pulp capping.
Due to their excellent bonding ability, resin adhesive
systems were suggested for pulp capping 20 years ago.
However, similar to GI/RMGI, adhesives are acidic and
have no bactericidal effects. Dental adhesives exhibited
poor pulpal healing, chronic inflammation, and lack
of dentin bridge formation, while the control calcium
hydroxide demonstrated good pulpal healing, dentin
bridge formation and no or slight inflammation2,49-53).
It is interesting to note that pulp capped directly with
non-acidic bonding resin or resin composite showed a
trend towards better pulp response than the ones capped
with acidic primers or adhesives51). Dental adhesive
should be avoided for direct pulp capping.
CONCLUSIONS
Based on this review, the following can be concluded
regarding direct pulp capping:
1. Resin adhesive systems, zinc oxide eugenols, and
glass ionomers/resin-modified glass ionomers
have been shown to have cytotoxic effects on
pulp cells. When used for direct pulp capping,
they exhibited chronic inflammation, poor pulpal
healing, and lack of dentin bridge formation, and
should be avoided for direct pulp capping.
2. Calcium hydroxide-base products include one-
paste non-setting calcium hydroxide systems,
two-paste self-setting calcium hydroxide systems,
6 Dent Mater J 2017; 36(1): 1–7
and light-curable resin-modified calcium
hydroxides. They all demonstrate antibacterial
properties and the ability to stimulate dentin
bridge formation. Calcium hydroxide has the
longest track record of clinical success and is
still considered the gold standard for direct pulp
capping. Two-paste calcium hydroxide systems
contain toxic components other than calcium
hydroxide, resulting in the higher cytotoxicity
than one-paste calcium hydroxide system.
3. Compared to calcium hydroxide, MTA/calcium
silicate materials have been shown to have less
cytotoxicity and better or comparable clinical
outcomes for direct pulp capping.
4. In vitro testing showed that light-curable resin-
modified calcium hydroxides or calcium silicates
did exhibit the higher cytotoxic effects than resin-
free version possibly because oxygen inhibition
layers were not first removed which may not be
clinically relevant since the tooth interface which
these materials come into contact with is oxygen
free. Light-curable resin-modified products have
the advantages of precise placement, command
set, superior physical strength, less solubility,
and reduced heavy metal release. Light-curable
products with hydrophilic polymer matrix
allowed the high release of calcium and hydroxide
ions. They are promising materials for dental
treatment of direct pulp capping.
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