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Use of Biodentine TM for Vital Pulp Therapy in Children: Three Case Reports

Article  in  Indian Journal of Public Health Research and Development · May 2020

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 Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05  341
TM
Use of Biodentine for Vital Pulp Therapy in Children:
Three Case Reports

Priyal P. Sheth1, Nikita V. Lolayekar2, Amitha M. Hegde3

1
Post Graduate Student, 2Reader, 3Senior Professor and Head of Department, Department of Pediatric and
Preventive Dentistry, A.B. Shetty Memorial Institute of Dental Sciences, Nitte (Deemed to be) University,
Mangalore, India

Abstract
There has been a paradigm shift from “extension for prevention” to “prevention of extension” in the clinical
approach of various treatment options for carious teeth. The choice of material often poses a challenge
while considering vital pulp therapy in primary and young permanent teeth. Tricalcium silicate materials are
believed to have superior properties when used in vital pulp therapy. Here, we report three individual cases
of asymptomatic, carious, primary and young permanent teeth, which have been treated with BiodentineTM
as a pulpotomy or pulp capping agent. Successful clinical and radiographic features were demonstrated at a
6-month follow up. The aim of this article is to highlight the properties of BiodentineTM and its reliability as
a material of choice in vital pulp therapy in primary and young permanent teeth.

Keywords:  Dental pulp capping; Pulpotomy; Silicate cements; Tricalcium silicate

Introduction With the advent of calcium silicate-based materials,

The ultimate goal of vital pulp therapy is the
induction of reparative tertiary dentin formation. The
success rate is not only dependent on appropriate case
selection, but also on the material used as a capping
agent. Calcium hydroxide has been the material of
choice for many decades, to augment pulp healing and
dentine repair. However, there are several demerits of
using this material that include tunnel defects formed
beneath dentinal bridges, inadequate sealing and
increased solubility in tissue fluids.1
Corresponding Author:
Dr. Nikita V Lolayekar, MDS
Reader, Department of Pediatric and Preventive
Dentistry, A.B. Shetty Memorial Institute of Dental
Sciences, Nitte (Deemed to be) University, Derlakatte,
Mangalore – 575018 Karnataka, India
Tel: +91-9886875769 Fax: +91-824-220-4572
e-mail: drnikitashanbhag@gmail.com
management of deep carious lesions has gained a whole
new perspective. Mineral Trioxide Aggregate (MTA),
introduced by Torabinejad M in 1993, is recognised as an
alternative gold standard material for conservative pulp
vitality treatments. Its ability to form a dentinal bridge to
protect the pulp more effectively than calcium hydroxide
makes it a suitable pulp-capping material.2 However,
MTA has shortcomings when used as a capping agent,
particularly in children, such as its prolonged setting
time, handling properties and possible discolouration
of teeth. Other biomaterials have been introduced to
overcome some of these limitations. One such tricalcium
silicate cement is BiodentineTM (Septodont, Saint-Maur-
des-Fossés, France), introduced in 2009, which is a
second-generation hydraulic calcium silicate cement.
Its reduced setting time aids in an immediate permanent
restoration without material deterioration, making it
appropriate for use in children.3
This article reports three cases where BiodentineTM
was used for pulpotomy, indirect pulp capping and direct
pulp capping, all aimed at preserving the vitality of the
teeth.
342  Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05
Case Reports:
Case Report 1: Pulpotomy: A 6-year-old boy
reported to the Department of Pediatric and Preventive
Dentistry with the chief complaint of decay in the
lower right back region of the jaw, with no history of
pain or swelling with respect to the same tooth. Clinical
examination revealed caries involving dentin with respect
to 84. On radiographic examination, the radiolucency
extended up to the inner third of the dentine, in close
proximity to the distal pulp horn. After discussing the
various treatment options, the parent consented to a
BiodentineTM pulpotomy, followed by a full coverage
permanent restoration.
After administration of local anaesthesia, rubber
dam was placed to isolate the tooth. The access cavity
was prepared with a #330 round diamond bur mounted
on a high-speed handpiece with copious water spray.
A sharp, 33L Endo excavator (Hu-Friedy) was used to
amputate the coronal pulp till the canal orifices. The
pulp chamber was then thoroughly irrigated with sterile
normal saline to ensure the removal of any pulpal tags
and dentinal debris. Moist cotton pellets were applied
with light pressure over the amputated pulp stumps for 5
minutes to achieve haemostasis.
BiodentineTM (Septodont, Sant-maur-des-fosses,
France) was mixed as per the manufacturer’s instructions
to obtain a creamy consistency and placed over the
pulpal floor and root canal orifices. A ball burnisher was
used to lightly condense the mix to achieve a thickness
of 2-3 mm. After 15 minutes of BiodentineTM hardening,
it was etched with the glass ionomer liquid. The glass
ionomer cement (Fuji IX, GC, Japan) was used to
restore the access cavity. (Figure 1A) At the 7-day
follow up, the tooth was evaluated for post-operative
pain and swelling, following which it was restored with
a preformed stainless steel crown.
The patient was reviewed after 1, 3 and 6 months
(Figure 1B) during which the tooth was asymptomatic,
both clinically and radiographically.
Case Report 2: Indirect Pulp Capping: A
12-year-old girl reported to the Department of Pediatric
and Preventive Dentistry for a routine dental check-up.
Clinical examination revealed a deep carious lesion with
respect to 26. On radiographic examination, the occlusal
radiolucency was approximating the pulp (Figure 2A).
There was no periapical radiolucency or widening of
the lamina dura. After discussing the various treatment
options, the parent consented to an indirect pulp capping
with BiodentineTM.
After the administration of local anaesthesia, the
tooth was isolated with a rubber dam. Carious enamel
and dentin was removed with a #330 round diamond bur
mounted on a handpiece following which a sharp, small
sized spoon excavator was used to excavate remaining
infected dentin, leaving behind firm affected dentine
over the pulp chamber. The cavity was irrigated with
normal saline to ensure complete removal of debris.
BiodentineTM (Septodont, Sant-maur-des-fosses,
France) was mixed as per the manufacturer’s instructions
to obtain a creamy consistency and placed over the
pulpal floor and root canal orifices. A ball burnisher was
used to lightly condense the mix to achieve a thickness
of 2-3 mm. After 15 minutes of BiodentineTM hardening,
it was etched with the glass ionomer liquid and the glass
ionomer cement (Fuji IX, GC Corporation, Japan) was
used as a base. The cavity was restored with a light-
cured resin composite (FiltekTM Z350 XT, 3M ESPE,
U.S.A.) to restore the functional anatomy of the tooth.
The patient was reviewed after 1 (Figure 2B),
3 and 6 months (Figure 2C) and she reported that the
tooth was asymptomatic. At the 1 month follow up
visit, radiographic evaluation revealed dentine bridge
formation over the pulpal chamber. Clinically and
radiographically there were no signs and/or symptoms
of endodontic disease associated with 26 and it elicited a
positive response when tested for pulp vitality.
Case Repost 3: Direct Pulp Capping: A 10-year-
old boy reported to the Department of Pediatric and
Preventive Dentistry with a chief complaint of food
lodgement in the upper left back tooth, with no other
associated symptoms. Clinical examination revealed a
deep carious lesion with respect to 26. On radiographic
examination, 26 showed radiolucency involving enamel,
dentine and in close proximity to the pulp (Figure 3A).
No periapical radiolucency or widening of lamina
dura was noted. After discussing the various treatment
options, the parent consented to a pulp capping procedure
with BiodentineTM, which would be direct or indirect,
as decided upon by the operator depending upon the
thickness of remaining healthy, unaffected dentine.
After administration of local anaesthesia, rubber
dam was placed to isolate the tooth. Carious enamel and
dentin was removed with a #330 round diamond bur
mounted on a handpiece. A sharp, small sized spoon
 Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05  343
excavator was used to excavate any remaining infected
dentin, in the process of which a sterile mechanical
exposure of the pulp chamber was encountered. A bright
red coloured pin-point bleed was noticed. The cavity was
irrigated with sterile saline and a moist cotton pellet was
placed over the pulpal wall for 2 minutes after which the
bleeding arrested.
BiodentineTM (Septodont, Sant-maur-des-fosses,
France) was mixed as per the manufacturer’s instructions
to obtain a creamy consistency and placed over the
pulpal floor and root canal orifices. A ball burnisher was
used to lightly condense the mix to achieve a thickness
of 2-3 mm. After 15 minutes of BiodentineTM hardening,
it was etched with the glass ionomer liquid and the glass
ionomer cement (Fuji IX, GC Corporation, Japan) was
used as a base. The cavity was then restored with a light-
cured resin composite (FiltekTM Z350 XT, 3M ESPE,
U.S.A.) to restore the functional anatomy of the tooth.
The patient was reviewed after 1 month and on
radiographic evaluation, a dentine bridge was seen to
be formed over the roof of the pulp chamber (Figure
3B). The patient was recalled at 3 and 6 months (Figure
3C) and reported that the tooth was asymptomatic.
Clinically and radiographically there were no signs and/
or symptoms of endodontic disease associated with 26
and it elicited a positive response when tested for pulp
vitality.

Figure 1: Pulpotomy. (A) Immediate post-operative radiograph. (B) Six-month follow up radiograph.

Figure 2: Indirect pulp capping. (A) Pre-operative radiograph. (B) One-month follow up radiograph;
formation of dentine bridge over the pulpal roof. (C) Six-month follow up radiograph.
344  Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05
Figure 3: Direct pulp capping. (A) Pre-operative radiograph. (B) One-month follow up radiograph;
formation of dentine bridge over the pulpal roof. (C) Six-month follow up radiograph.
Table 1. Composition of BiodentineTM.
Powder Liquid
Tricalcium silicate Water
Zirconium oxide Calcium chloride
Calcium carbonate Water soluble polymer
Iron oxide – to give the colour
Discussion
Tooth structure may be lost either by dental caries,
trauma or tooth wear and is often replaced by inert dental
materials to replace the bulk of the tooth. The hydraulic
nature is characteristic to all calcium silicate cements.
Their applicability in areas that cannot be completely
isolated from body fluids gives them an advantage over
the other routinely used materials.
BiodentineTM is available as a capsule-ampoule
system, containing the powder and liquid respectively.
Its composition is as shown in Table 1.3 Hydraulic
calcium silicate stimulates the recruitment of the
cells of the pulp to differentiate into odontoblasts
to promote dentinogenesis, by upregulation of
transformation factors4 Calcium carbonate in the
powder provides a site for nucleation, for crystal growth
and mineralisation.5Zirconium oxide provides adequate
radiopacity and accounts for stability, ensuring no
leaching out and thereby no discolouration externally,
as opposed to the materials containing bismuth oxide.3
The setting reaction between the tricalcium silicate
and water results in the formation of a hydrated calcium
silicate gel and calcium hydroxide.6This gel precipitates
around the calcium carbonate, which in turn provides a
site for nucleation and strengthens the microstructure.7
This precipitate resembles hydroxyapatite crystals. The
calcium hydroxide which is released as a by-product of
the hydration reaction makes this material ideal for use as
a pulp capping material, for apexification, apexogenesis
and regenerative endodontic procedures. Calcium
hydroxide dissociates into calcium and hydroxyl ions
that are responsible for its favourable properties like its
high antibacterial property.
The choice of material is important for successful
clinical outcome.3 Materials used to seal the remaining
pulp in vital pulp therapies must have a good sealing
property. Any leakage may result in postoperative
sensitivity and secondary caries, compromising the
success of the treatment. Koubi et al7 assessed the in
vitro marginal integrity and reported BiodentineTM’s
performance to be equivalent to that of resin modified
glass ionomer cement. The hydroxyapatite crystals at
the surface of BiodentineTM cement have the potential
to increase its sealing ability eliminating the specific
preparation of the dentinal walls, which is a pre-requisite
for most other materials.8
The duration of a clinical procedure is of critical
importance while treating children. The initial setting
time of BiodentineTM is said to be 9 to 12 minutes.3 This
can be attributed to the inclusion of calcium chloride,
which accelerates the setting time.5 A decreased setting
 Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05  345
time is one of the most clinically relevant advantages
of BiodentineTM and it was thus preferred over other
capping materials in the aforementioned case reports.
An important physical property of this material is
its compressive strength. It is crucial to the success of a
hydraulic cement used in vital pulp therapy. It signifies
the ability of the material to withstand the masticatory
forces to resist external impacts.8 Biodentine exhibited
a compressive strength of 170 MPa after 24 hours and
a significant increase to 340 MPa post exposure to
moisture for 28 days as concluded by Naziya et al.9
The most desirable property of any material
used in vital pulp therapy, is its potential to induce
dentinogenesis. BiodentineTM has shown to bring about
an increased secretion of TGF-β1 from human dental
pulp stem cells.10 A well-arranged layer of odontoblasts
and odontoblast-like cells is found to form tubular
dentin under the osteodentin. Several in vitro and in
vivo studies have shown that the dentin bridge formation
and root dentin formation is more homogenous than
that formed by calcium hydroxide-based materials.11
It has successfully been used as a pulp capping agent
in not only accidental exposure of healthy pulp, but
also carious or traumatic exposure of the pulp.12 This
property substantiates the use of BiodentineTM as a
direct pulp capping agent in the case reported herewith.
Shortcomings of this material, such as the
discolouration of restorations have been reported in
literature. A study by Lipski et al observed a yellowish
discolouration of restorations which they attributed to the
lower abrasive wear resistance, porosity of BiodentineTM
and the absorption of dyes from saliva.1 Discolouration
of restorations was not encountered in the cases reported
above.
Considering its properties and advantages,
BiodentineTM was chosen as the material of choice in
the management of the above-mentioned cases.
Conclusion
As seen from the above case reports, the dentinal
bridge was seen to be formed within a month of
application of BiodentineTM. It offers a valuable
alternative intervention to maintain the vitality of dental
pulp in teeth with deep seated carious lesions. Its physico-
mechanical and handling properties along with a shorter
setting time allows for its clinical use as a conventional
dentine substitute. More clinical studies need to be
conducted to validate these observations. Conservative
techniques that improve treatment outcomes in cariously
involved primary and young permanent teeth should be
encouraged.
Acknowledgements: The authors would like to
extend their gratitude to the Department of Pedodontics
and Preventive Dentistry at A. B. Shetty Institute
Memorial of Dental Sciences, Mangalore, Nitte
(Deemed-to-be) University for extending their support
and resources needed for the study.
Conflict of Interest: Nil
Source of Funding: Self-funded
Ethical Clearance: Taken from the institution
ethical committee, after obtaining individual consent
from each of the patients reported in the above mentioned
case reports.
References
1. Lipski M, Nowicka A, Kot K, Postek-Stefanska,
Wysoczanska-Jankowicz I, Borkowski L, et al.
Factors affecting the outcomes of direct pulp
capping using BiodentineTM. Clin Oral Investig.
2018 Jun;22(5):2021-29.
2. Torabinajed M, Hong CU, McDonald F, Pitt Ford
TR. Physical and chemical properties of a new
root-end filling material. J Endod 1995 Jul;21(7):
349‑53.
3. Camilleri J. BiodentineTM: the dentine in a capsule
or more? (Internet). Available from: http://www.
septodontcorp.com/wp-content/uploads/2018/02/
Biodentine-Article-0118-LOW.pdf.
4. Rajasekharan S, Martens LC, Cauwels RG,
Verbeeck RM. Biodentine™ material characteristics
and clinical applications: a review of the literature.
Eur Arch Paediatr Dent. 2014 Jun;15(3):147-58.
5. Grech L, Mallia B, Camilleri J. Characterization of
set Intermediate Restorative Material, Biodentine,
Bioaggregate and a prototype calcium silicate
cement for use as root-end filling materials. Int
Endod J. 2013 Jul;46(7):632-41.
6. Grech L, Mallia B, Camilleri J. Investigation of the
physical properties of tricalcium silicate cement-
based root-end filling materials. Dent Mater. 2013
Feb;29(2):e20-8.
7. Koubi S, Elmerini H, Koubi G, Tassery H, Camps
J. Quantitative evaluation by glucose diffusion of
 346  Indian Journal of Public Health Research & Development, May 2020, Vol. 11, No. 05
microleakage in aged calcium silicate-based open-
sandwich restorations. Int J Dent. 2012;2012:105863.
http://dx.doi.org/10.1155/2012/105863 (Epub 2011
Dec 12).
8. Malkondu Ö, Kazandağ MK, Kazazoğlu E.
A review on BiodentineTM, a contemporary
dentine replacement and repair material. Biomed
Res Int. 2014;2014:160951. http://dx.doi.
org/10.1155/2014/160951.
9. Butt N, Talwar S, Chaudhry S, Nawal RR, Yadav
S, Bali A. Comparison of physical and mechanical
properties of Mineral Trioxide Aggregate and
BiodentineTM.Indian J Dent Res. 2014 Nov-
Dec;25(6):692-7.
View publication stats
10. Laurent P, Camps J, About I. BiodentineTM induces
TGF-β1 release from human pulp cells and early
dental pulp mineralization. Int Endod J. 2012
May;45(5):439-48.
11. Villat C, Grosgogeat B, Seux D, Farge P.
Conservative approach of a symptomatic carious
immature permanent tooth using a tricalcium
silicate cement (BiodentineTM): A case report.
Restor Dent Endod. 2013 Nov; 38(4): 258–262.
12. Nowicka A, Lipski M, Parafiniuk M, Sporniak-
Tutak K, Lichota D, Kosierkiewicz A, et. al.
Response of human dental pulp capped with
BiodentineTM and Mineral Trioxide Aggregate. J
Endod 2013 Jun;39(6):743-7.