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185]

Review Article

Biodentine versus mineral trioxide aggregate as

a direct pulp capping material for human mature
permanent teeth – A systematic review
Salah H. Mahmoud, Salwa A. El-Negoly1, Ahmed M. Zaen El-Din2, Mona H. El-Zekrid3, Lamyaa M. Grawish4,
Hala M. Grawish4, Mohammed E. Grawish3
Departments of Operative Dentistry, 1Dental Biomaterials and 3Oral Biology, Faculty of Dentistry, Mansoura University, 2Department of
Operative Dentistry and 4Undergraduate Students, Faculty of Oral and Dental Medicine, Delta University for Science and Technology,
Mansoura, Egypt

Abstract
Background: Biodentine is comparatively a new biomaterial claimed to have properties comparable to mineral trioxide
aggregate (MTA). Biodentine and MTA are effectively used for direct pulp capping (DPC), and they are capable of regenerating
relatively damaged pulp and formation of hard dentine bridge.
Objectives: The aim of this systematic review was to test the null hypothesis of no difference between Biodentine and MTA as
DPC materials for human permanent mature teeth, against the alternative hypothesis of a difference.
Data Sources: Clinical trials were identified by electronic databases searches of Midline, CENTRAL Cochrane Library,
Latin American and Caribbean Health Sciences Literature, Scopus, Scientific Electronic Library Online, evidence‑based
endodontics literature, KoreaMed, and Google Scholar. The literature search was performed from January 2010 to
February 2018. Hand searches were also performed for relevant abstracts, books, and reference lists. Titles and
abstracts of studies identified using the above‑described protocol were independently screened by two authors. Full texts
of studies judged by title and abstracts to be relevant were independently evaluated by two authors for stated eligibility
criteria.
Study Eligibility Criteria: The eligibility criteria included randomized clinical trials (RCTs) and non‑RCTs.
Participants: Patients with permanent mature molars indicated for surgical extraction or molars that have symptomless exposure
of vital pulp tissue by caries or trauma. In both cases, the molars were subjected to DPC.
Interventions: The pulp exposures were directly treated by Biodentine or MTA.
Study Appraisal: To assess article quality, two authors independently used the risk of bias in nonrandomized studies – of interventions.
Methods: Qualitative metasynthesis was used to analyze data across qualitative studies.
Results: The initial search identified 8725 unique references through the search process. No additional studies were identified
through handsearching. After filtering, 915 references were recorded and screened. After the eligibility criteria were applied,
seven unduplicated prospective and retrospective cohort studies were included in the qualitative metasynthesis.
Limitations: Further RCTs with much larger sample size and proper methodology with longer observational time are still in need
to adequately address the questions of the present systematic review.

Address for correspondence:

Prof. Mohammed E. Grawish, Faculty of Dentistry,
Mansoura University, Mansoura, Egypt.
This is an open access journal, and articles are distributed under the terms
E‑mail: grawish2005@yahoo.com
of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
Date of submission : 23.04.2018 License, which allows others to remix, tweak, and build upon the work
Review completed : 21.07.2018 non‑commercially, as long as appropriate credit is given and the new
Date of acceptance : 29.07.2018 creations are licensed under the identical terms.
Access this article online For reprints contact: reprints@medknow.com
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Website:
How to cite this article: Mahmoud SH, El-Negoly SA,
www.jcd.org.in
Zaen El-Din AM, El-Zekrid MH, Grawish LM, Grawish HM,
et al. Biodentine versus mineral trioxide aggregate as a direct
DOI: pulp capping material for human mature permanent teeth – A
10.4103/JCD.JCD_198_18
systematic review. J Conserv Dent 2018;21:466-73.

466 © 2018 Journal of Conservative Dentistry | Published by Wolters Kluwer - Medknow

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Mahmoud, et al.: Bioactive materials for direct pulp capping of permanent teeth

Conclusion and Implications of Key Findings: Within the limitations of this review, it may be concluded that Biodentine had
a similar effect on dentin bridge formation likely to MTA. However, this conclusion is based on only very few well‑conducted
prospective and retrospective cohort studies.
Systematic Review Registration Number: The review had been registered with PROSPERO (registration number
CRD42018089302).
Keywords: Biodentine; dentin bridge formation; direct pulp capping; mineral trioxide aggregate; permanent molars

INTRODUCTION by chance into separate groups.[12] The British physician

Pulp exposure can be due to trauma, mechanical reasons,
or caries. Direct pulp capping (DPC) may be required as one
of the treatment options to prevent the dental pulp from
necrosis.[1] Ideal pulp capping material should maintain
pulpal vitality and stimulate reparative dentin formation.[2]
These materials should possess certain properties such
as radiopacity, insolubility, dimensional stability,
biocompatibility, bioactivity, and adequate adhesive ability
to both the dentin and to the restorative materials.[3] It
should also release fluoride, provide bacterial seal, prevent
secondary caries, should have bactericidal or bacteriostatic
activity against the causative pathogens, and promote the
formation of mineralized tissue.[4]
Till date, calcium hydroxide (CH), mineral trioxide
aggregate (MTA), and tricalcium silicate cement (Biodentine)
are the materials of choice which have been most commonly
used in clinics.[5] Although CH has been considered as the
gold standard for pulp capping, it still has several drawbacks,
namely, insufficient adherence to dentin, multiple tunnel
defects in the dentin bridges, and dissolution over time.[6]
The two main components of MTA are calcium oxide and
silicon dioxide. When these raw materials are blended, they
produce tricalcium silicate, dicalcium silicate, tricalcium
aluminate, tetracalcium aluminoferrite, and other mineral
oxides. Bismuth oxide was added so that the material can
be detected on radiographs . On addition of water, the
cement hydrates, form silicate hydrate gel.[7] Gray MTA was
the original formulation to be introduced, and white MTA
was developed later as this version improved esthetics.[8]
Disadvantages of MTA are that it is highly soluble and has a
prolonged setting more than 2 h.[9] Meanwhile, Biodentine
is a two components material; the powder component
consists of tricalcium silicate, dicalcium silicate as a second
core material, calcium carbonate, oxide as filler, iron oxide
shade, and zirconium oxide as a radioopacifier. The liquid,
on the other hand, contains calcium chloride as a setting
accelerator and a water reducing agent.[10] There is ample
evidence for positive effects of Biodentine on vital pulp
cells, for stimulating tertiary dentin formation, and early
formation of reparative dentin.[11]
The gold standard of experimental design is the randomized
clinical trials (RCTs), in which participants are divided
Archie Cochrane contributed greatly to the development of
epidemiology as a science, and he was concerned about the
efficacy of health care. Cochrane emphasized the necessity
of performing strict systematic review with high scientific
evidence from well‑designed and well‑conducted RCTs of
medical studies to acquire a true and reliable conclusion.[13]
The Oxford Centre for Evidence‑based Medicine considers
systematic reviews of RCTs as Level 1 according to the
levels of evidence (LoE) corresponding to study design.[14]
The rationale for conducting this systematic review arose
from the fact that a reliable biomaterial for DPC may be
considered as an alternative to pulpectomy, especially if
the pulp status is favorable. Biodentine has been recently
introduced on the market to overcome the limitations
of MTA as long setting time, poor handling properties,
cost, and the potential discoloration of teeth and soft
tissue. Accordingly, this systematic review will provide
decision‑making process based on scientific evidence for
the clinician and health‑care provider to select the material
of choice as a DPC. The aim of this study was to conduct
a systematic review on the efficacy of Biodentine versus
MTA as DPC materials for human permanent teeth. This
objective was based on a research question; is there is a
difference between Biodentine and MTA as DPC materials
for permanent mature teeth.
METHODS
Protocol and registration
The methodology of this systematic review was done on
the basis of the guidelines of the Preferred Reporting Items
for Systematic Reviews and Meta‑analyses checklist.[15] The
review had been registered with international prospective
register of systematic reviews (PROSPERO) (registration
number CRD42018089302). The clinical question was
formulated and organized using the PICO strategy for the
research question construction.
Eligibility criteria
The inclusion criteria included were as follows: (1) studies
are RCTs or non‑RCTs; (2) all selected teeth were permanent
molars with symptomless exposure of vital pulp tissue by
caries or trauma; (3) the pulp exposures were treated by
Biodentine or MTA; (4) all selected teeth had a 1‑month
follow‑up time at least; and (5) the outcome was evaluated

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Mahmoud, et al.: Bioactive materials for direct pulp capping of permanent teeth
by clinical symptoms and/or radiographic evidence. The
exclusion criteria were (1) immature teeth, (2) primary
teeth, (3) studies assessed mechanical or physical
properties of the materials, (4) negative control group
which does not have a capping material, (5) indirect pulp
capping, pulpotomy, and pulpectomy, and (6) animal and
laboratory‑based studies, qualitative and/or quantitative
reviews, commentaries, case reports/case series, and
letters to the editor.
Information sources and search strategy
The PROSPERO and the Cochrane Database of Systematic
Reviews were searched in February 2018 and presented
no existing reviews that were found comparing the effect
of these two materials as a DPC for permanent teeth. To
identify published clinical trials relevant to the focused
question, all searches were conducted independently by
two authors (MG and SE). A literature search was conducted
based on multiple electronic databases (PubMed [Midline],
CENTRAL Cochrane Library, Latin American and Caribbean
Health Sciences Literature, Scopus, Scientific Electronic
Library Online, evidence‑based endodontics literature,
KoreaMed records [KoreaMed], and Google Scholar). The
literature search was performed from January 2010 to
February 2018, based on a predetermined PICOS statement.
The population was adult patients; the intervention was
tricalcium silicate cement/Biodentine; the comparator was
MTA; the outcome was the efficacy of these two materials
as a DPC; and the study designs were clinical trials. Medical
subject headings terms, “dental pulp capping” and “pulp
capping and pulpectomy agents,” were used in our
search. Other search words or terms were used in search
strategy [Table 1]. The search strategy used in PubMed was
adjusted for use in the other databases. These keywords
were used with Boolean operators AND, OR, and NOT.
References of the identified studies were handsearched
to identify further potentially relevant studies, relevant
conference proceedings, and relevant abstracts; books
as well as searching gray literatures were performed.
Any disagreements in the study selection were resolved
through discussion with a third author (SM).
Study selection and data collection
Two authors (AZ and MZ) screened all the titles and abstracts
and selected only studies related to DPC materials in
accordance with the eligibility criteria. They independently
tabulated the data of interest. From the studies included,
the following data were tabulated: authors and their
country, study design, journal (year of publication), age
and gender of study individuals, study groups, vital pulp
treatment, type of material evaluated, follow‑up in days, and
the type of teeth evaluated. Authors of the studies included
were contacted through electronic mail in case data were
missing or additional information regarding their studies
was required. Fields for which information could not be
found in a publication or online abstract were entered as
468 Journal of Conservative Dentistry | Volume 21 | Issue 5 | September-October 2018
“unknown” and were either excluded in the subsequent
meta‑analysis or included as “unknown [Table 2].”
Risk of bias in individual studies
To assess article quality, two authors (SM and SE)
independently used the “risk of bias (RoB) in nonrandomized
studies – of interventions.”[23] It is concerned with
evaluating the RoB in the results of nonrandomized studies
of the effects of interventions that compare the health
effects of two or more interventions. Each criterion was
rated as “Yes,” “Probably yes,” “Probably no,” “No,” and “No
information [Table 3].” For consistency, any disagreements
in the assessment were resolved through discussion with a
third author (MG).
Statistical analysis
Degree of chance – adjusted agreement (kappa coefficient
value) was used to determine the inter‑reviewer reliability.
RESULTS
Study selection
The initial search identified 8725 unique references
through the search process. No additional studies
were identified through handsearching. After filtering,
915 references were recorded and screened. After the
eligibility criteria were applied, seven unduplicated
prospective and retrospective cohort studies were
obtained and were included in the present review [Table 1
and Figure 1]. The kappa value for interexaminer’s
agreements was 0.79.
Study characteristics
One study was performed in 2013 (Poland), two at
2015 (Poland and Republic of Macedonia), one in
2016 (Pakistan), and three in 2017 (India and Saudi Arabia).
Six of them were prospective observational studies while
the remaining one was pilot retrospective study. Two
studies were done by Nowicka et al.[16,18] evaluating the
clinical and histological response of human dental pulp
capped with Biodentine or MTA. Clinical examination
was done through thermal and electric testing, and in
addition, plain radiographs and tomographic evaluation
using CBCT imaging were performed. Histologically, they
evaluated continuity, morphology and thickness of hard
tissue formation, type, intensity and extension of pulp
inflammation, and other histologic features. Moreover, one
study[17] carried their trial on two levels, clinical testing and
pathohistological one. The pathohistological evaluation
was for dentin bridge morphology, type and intensity of pulp
inflammation, and other histological features [Table 4]. The
clinical and radiological evaluations were performed after
8 and 30 days for the vitality of teeth, subjective symptoms,
and amount of reparative dentin formation. The other four
studies recorded the postoperative pain of patients included
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Mahmoud, et al.: Bioactive materials for direct pulp capping of permanent teeth
Table 1: Databases involved and the search terms used with the number of references obtained after filtering and
applying the eligibility criteria
Database Search terms (number of references)
PubMed (advanced search) ((Direct [All Fields] AND “dental
pulp capping” [MeSH Terms]) OR
MTA[Title/Abstract]) OR Biodentine
[Title/Abstract] (4007)
((Direct [All Fields] AND “pulp capping
and pulpectomy agents” [MeSH Terms])
OR MTA [Title/Abstract]) OR Biodentine
[Title/Abstract] (3719)
Central Cochrane Library MeSH descriptor: [Dental Pulp Capping]
(advanced search) AND “MTA”:ti, ab, kw OR “Biodentine”:ti,
ab, kw (30)
MeSH descriptor: [Pulp Capping and
Pulpectomy Agents] AND “MTA”:ti, ab, kw
or “Biodentine”:ti, ab, kw (32)
LILACS Direct pulp capping (Title) (22)
Scopus (advanced search) TITLE‑ABS‑KEY (dental AND pulp AND
capping) AND TITLE‑ABS‑KEY (mta) AND
TITLE‑ABS‑KEY (Biodentine) (44)
Scielo (ab:(pulp capping)) OR (ab:(MTA))
OR (ab:(Biodentine)) (222)
EBE pulp capping (Title), category (All), EB
Ranking (All), Display (All) (5)
KoreaMed “pulp capping” [ALL] (14)
Google scholar Direct pulp capping of permanent molars
using MTA and Biodentine (630)
Total 8725
MTA: Mineral trioxide aggregate
using visual analog scale after 7 days, 1 month, 3 months,
and 6 months. In addition, postoperative radiographs were
taken on 3‑month and 6‑month recall visits to detect any
apical radiolucency,[19] assessed the pulpal health after
3 weeks, 3 months, 6 months, and 1 year using thermal and
electrical pulp sensitivity testing, and in addition, 6‑month
follow‑up radiographs were taken,[20] analyzed the clinical
and radiographic recall data at intervals of 1, 3, 6, 12, and
18 months. The data were comprised pain, sensibility status
of the teeth, radiographic signs of periapical pathology, and
dentin bridge formation[21] and were performed clinical and
radiological examination after 1‑year recall.[22]
Journal of Conservative Dentistry | Volume 21 | Issue 5 | September-October 2018
Filter (number of references) I/E criteria (number of
references)
Clinical trial, publication date from (2)
2010/01/01, Adult: 19+ years (37) Nowicka et al. 2013
Nowicka et al. 2015
Clinical trial, publication date from
2010/01/01, Adult: 19+ years (34)
Publication year from 2010, in (1)
trials (17( Nowicka et al. 2015
(duplicated)
Publication year from 2010, in
trials (31)
ti:(ti:(direct pulp capping) 0
AND (instance: “regional”)
AND (db:(“LILACS”) AND mj:(“Dental
Pulp Capping” OR “Biocompatible
Materials” OR “Dental Pulp
Exposure”) AND limit:(“humans”)))
AND (instance:”regional”) (5)
AND (LIMIT‑TO (PUBYEAR, 2018) (4)
OR LIMIT‑TO (PUBYEAR, 2017) Nowicka et al.
OR LIMIT‑TO (PUBYEAR, 2016) 2013 (Duplicated)‑ ‑Nowicka
OR LIMIT‑TO (PUBYEAR, 2015) et al. 2015 (Duplicated)
OR LIMIT‑TO (PUBYEAR, 2014) Eftimoska et al. 2015
OR LIMIT‑TO (PUBYEAR, 2013) Hegde et al. 2017
OR LIMIT‑TO (PUBYEAR, 2012))
AND (LIMIT‑TO (DOCTYPE, “ar”))(41)
AND year_cluster: (“2013” OR 0
“2016” OR “2014” OR “2015” OR
“2017” OR “2010” OR “2011”
OR “2012” OR “2018”) AND
type: (“research‑article”) (160)
Publication date from Jan 2010 (1) 0
(2010:2018 [DP]) AND (“Clinical 0
Trial” [PT]) AND (“Humans” [MH])
AND (“Adult” [MH] (0)
2010:2018 (589) (5)
Nowicka et al. 2013
(Duplicated)
Sidrah Shafaat et al. 2016
Sabrah and Alqahtani 2017
Linu et al. 2017
Hegde et al. 2017
(duplicated)
915 7 (nonduplicated)
Risk of bias within studies
Heterogeneity was found between the previous studies.[16‑22]
as they used different methods of evaluation (histological,
clinical, and radiological), and in addition, different scores
for the amount of dentin bridge formation were used in
histological and radiological assessments. Pulp vitality was
assessed with different parameters; moreover, dichotomous
data were sometimes used, and in other instances,
continuous data were the main outcome. Common study
limitations included inadequate randomization and
allocation concealment, nonreporting of study withdrawals
and participants lost to follow‑up, lack of blinding of
469
 Table 2: Characteristics of the studies included

470
Author (country) Study design Study subjects Journal Study Teeth evaluated Vital pulp Type of material Number of Follow‑up Evaluation Outcome
(age and gender) (publication year) groups treatment evaluated patients in days method
Nowicka Prospective (19‑28 years, J Endod. (2013) 2 parallel 28 intact DPC Biodentine 18 42 days Clinical and Biodentine had a
et al. (Poland)[16] observational unknown) groups maxillary and MTA histological similar efficacy
studies mandibular examination in the clinical
permanent setting and may
human third be considered
molars an interesting
alternative to MTA
as a DPC material
Eftimoska et al. Prospective (18‑40 years, RJPBCS (2015) three 84 incisors, DPC Calxyl Unknown 8 and Clinical and From all the three
Republic of observational both gender) parallel canines, MTA 30 days pathohistological groups, the rate
Macedonia)[17] studies groups premolars, Biodentine evaluation of the successfully
and molars; repaired pulp
60 for clinical, exposures after a
indicated for period of evaluation
DPC and 24 was greater in those
intact for cases where MTA
pathohistological and Biodentine were
used as materials for
direct capping
Nowicka Prospective (19‑32 years, J Endod. (2015) 4 parallel 44 intact DPC CH 21 42 days Tomographic Biodentine and
et al. (Poland)[18] observational mean 26 years, groups maxillary and MTA evaluation MTA resulted in the
studies unknown) mandibular Biodentine Histological formation of bridges
human third Single Bond examination with a significantly
molar Universal higher average
volume compared
with Single Bond
Mahmoud, et al.: Bioactive materials for direct pulp capping of permanent teeth

Universal
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Shafaat Prospective 19‑50 years, Pak Oral Dental J Two 100 carious DPC MTA 100 30, 90, Pain was Chi‑square test
et al. (Pakistan)[19] observational 51 (male) and 49 (2016) parallel maxillary and Biodentine and 180 recorded using demonstrated
studies (females) groups mandibular days visual analog no significant
asymptomatic scale difference between
vital permanent both study groups
first and second throughout the
molars course of clinical
study
Hegde et al. (India)[20] Prospective (18‑40 years, J Conserv Dent. Two 24 permanent DPC MTA Unknown 90, 180, Clinical and MTA and Biodentine

Journal of Conservative Dentistry | Volume 21 | Issue 5 | September-October 2018

observational unknown) (2017) parallel molars with Biodentine and 180 radiographic showed 91.7% and
studies groups carious exposure days evaluation 83.3% success rate,
having no signs respectively
and symptoms
of irreversible
pulpitis

Contd...
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Mahmoud, et al.: Bioactive materials for direct pulp capping of permanent teeth

MTA and Biodentine

Records identified through Google Additional records identified through

overall success rate

direct pulp capping

better properties in
84.6% and 92.3%,

and MTA and has

Scholar database searching other sourcesMIDLINE (n = 7726)

Biodentine shows
respectively, with

compared to CH
success rates of

no failure cases
(n = 630) CENTRAL Cochrane Library (n = 62)

groups showed
LILACS (n = 22)
Scopus (n = 44)

of 88.5%
Outcome

recorded
Scielo (n = 222)
EBE (n = 5)

Identification
KoreaMed (n = 14)

radiographic

radiographic
365 days Clinical and
Type of material Number of Follow‑up Evaluation

symptoms,

evaluation
sensibility
tests, and
Based on

analysis
in days method

Records after filtering

(n = 915)

Screening
30‑540
days

Records screened Records excluded

(n = 915) (n = 908)
patients

patients

patients

Full-text articles assessed Full-text articles excluded,

30

72

for eligibility with reasons

Eligibility
(n = 7) (n = 0)
Biodentine

Biodentine
evaluated

Studies included in
qualitative synthesis
MTA

MTA

(n = 7)
CH

Included
Vital pulp
treatment

Studies of quantitative
data but heterogeneous
DPC

DPC

(n = 4)
permanent teeth
Teeth evaluated

Figure 1: Flowchart for article selection according to preferred

with carious

reporting items for systematic reviews and meta‑analyses

30 mature

Unknown
exposure

guidelines

outcome assessor, contamination, and failure to perform

an intention to treat analysis. Four studies had moderate
parallel

parallel
(publication year) groups

groups

groups
Study

RoB, two had serious RoB, and one had critical RoB.
three
two

DISCUSSION
J Endod. (2017)

Med. Res. Chron

MTA: Mineral trioxide aggregate, DPC: Direct pulp capping, CH: Calcium hydroxide

A systematic review, by virtue of the method used to

Journal

(2017)

collect information, provides a solid base for clinical

decision‑making, due to its high LoE. It is a systematic
assessment of the available literature for the effects of
(age and gender)

health‑care interventions and is an assessment that is

Study design Study subjects

18‑40 years,
15‑30 years

intended to help professionals in choosing the appropriate

observational unknown

treatment.[24]

The main findings of the included studies were dentin

retrospective

Sabrah and Alqahtani Prospective

bridge formation, inflammatory cell infiltration, amount

of pulp necrosis, and pulp vitality. With regard to dentin
A Pilot

studies
Study

bridge formation, it was found that Biodentine and

MTA are likely to promote the formation of reparative
dentin, and they have positive results on odontoblasts
Linu et al. (India)[21]
Table 2: Contd...

(Saudi Arabia)[22]

when used in DPC. Biodentine and MTA are used in pulp

Author (country)

capping due to their involvement in mineralized tissue

bridge formation, the preservation of pulpal vitality, and
promotion of odontoblast layer integrity.[25] For health‑care
provider and clinicians, Biodentine is new bioactive cement

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Table 3: Quality assessment of included studies

Author Preintervention At intervention Postintervention
(year of publication) Bias due to Bias in selection Bias in Bias due to deviations Bias due Bias in Bias in RoB
confounding of participants classification of from intended to missing measurement selection of the judgment
into the study interventions interventions data of outcomes reported result
Nowicka et al. 2013 Probably no Probably no Probably no Probably no No No No Moderate
risk
Eftimoska et al. Properly no Properly no Yes Properly yes No No Properly yes Serious
2015 risk
Nowicka et al. 2015 Probably no Probably no Probably no Probably no No No No Moderate
risk
Sidrah Shafaat et al. Probably no No Properly no Probably no No No Probably no Moderate
2016 risk
Hegde et al. 2017 Probably no Probably no Probably no Probably no No No No Moderate
risk
Linu et al. 2017 Probably no Probably no Probably no Probably no No No No Moderate
risk
Sabrah and Properly yes Properly yes Properly yes Properly yes Properly Properly yes Properly yes Critical
Alqahtani 2017 yes risk
Low: “Comparable to a well‑performed randomized trial”, Moderate: “Sound for a nonrandomized study but cannot be considered comparable to a well‑performed randomized
trial”, Serious: “presence of important problems”, Critical: “Too problematic to provide any useful evidence on the effects of intervention”, No information: “Insufficient
information provided to determine RoB”. RoB: Risk of bias

Table 4: Heterogeneity assessment of included studies

Author Cavity Exposure diameter Permanent Postoperative Measurements
(year of publication) classification restoration examination
Nowicka et al. 2013 Occlusal Class I Approximately 1.2 Composite Thermal testing Assess pulp health
cavities mm in diameter restoration Electric sensitivity Assess pulp health
testing Observe signs of periapical
Plain radiographs pathology‑continuity, morphology, and
Histological scoring thickness of dentinal bridge
Type, intensity, and extensity of pulp
inflammation
Odontoblastic layer
Bacterial penetration
Eftimoska et al. Occlusal Class I Exposure Glass ionomer Clinical tests Subjective feeling of pain
2015 cavities was of small or composite Pathohistological tests Vitality of the teeth
dimension (unknown) restoration Presence of caries
Morphology of dentinal bridge
Type and intensity of pulp inflammation
Other histological features (odontoblastic
layer)
Nowicka et al. 2015 Occlusal Class I Approximately 1.2 Composite Thermal testing Assess pulp health
cavities mm in diameter restoration Electric sensitivity Assess pulp health
testing Identify volume, intensity of dentin bridges.
CBCT Dentinal bridge continuity, morphology,
Histological scoring and thickness
Pulp inflammation type, intensity, and
extensity
Odontoblastic layer
Bacterial penetration
Sidrah Shafaat et al. Unknown Unknown Composite Visual analog scale Postoperative pain
2016 restoration
Hegde et al. 2017 Unknown Unknown Composite Thermal and electric Assess pulp health
restoration pulp sensitivity testing Detect the formation of dentin bridge
Postoperative
radiographs
Linu et al. 2017 Unknown Unknown Resin‑bonded Percussion Assess pain
composite Sensibility status of the Assess pulp health
teeth Assess periapical pathology and dentin
Radiographs bridge formation
Sabrah and Unknown Unknown Unknown Unknown Asses failure
Alqahtani 2017
CBCT: Cone beam computed tomography

that is similar to the widely used MTA. It has dentin‑like material for clinical indications of dentin‑pulp complex
mechanical properties, which may be considered a suitable regeneration such as DPC.

472 Journal of Conservative Dentistry | Volume 21 | Issue 5 | September-October 2018

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Mahmoud, et al.: Bioactive materials for direct pulp capping of permanent teeth
The main appeal of the RCT in health care comes from its
potential to reduce selection bias. In the present systematic
review, all the included studies were parallel groups
without randomization and this can be attributed to the
little number of participant involved in each study. Studies
with small sample sizes have a tendency to be less reliable
and are more probably inconclusive due to inadequate
statistical power.[26] In addition, the study designs were
based in some studies on using sound molar teeth, and in
others, they depend on carious teeth. From the biological
point of view, the pulp will respond differentially in both
situations even at the basis of the molecular level with
differential molecular interactions that potentially affect
the final outcome. The major causes of postoperative
inflammation and pulp necrosis are nonsterile procedures
and bacterial micro‑infiltration of the pulp through dentin
tubules.[27]
Among the drawbacks of the included studies were
the short time follow‑up evaluation periods. Dentin
formation usually starts within 30 days of the pulp capping
(there can be a delay in onset of dentin formation if the
odontoblasts of the pulp are injured during cavity removal)
and is largely completed by 130 days.[28] Moreover, the
size of the pulp exposure is not considerably consistent
in the included studies. The success of the pulp capping
procedure greatly depends on the circumstances under
which it is performed, and the prognosis depends on the
age, type, site, and size of pulp exposure.[29]
The outcomes of the present systematic review should be
taken with caution due to the presence of uncontrolled
confounding factors in the included clinical trials. Within
the limitations of the existing clinical trials, the results of
the present study suggest that the Biodentine had a similar
effect on dentin bridge formation likely to MTA. However,
this conclusion is based on only very few well‑conducted
prospective and retrospective cohort studies.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Journal of Conservative Dentistry | Volume 21 | Issue 5 | September-October 2018
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