ORIGINAL ARTICLE

International Dental Journal 2012; 62: 3339

doi: 10.1111/j.1875-595X.2011.00084.x

Evaluation of mineral trioxide aggregate (MTA) versus

calcium hydroxide cement (Dycal) in the formation
of a dentine bridge: a randomised controlled trial
Fatou Leye Benoist1, Fatou Gaye Ndiaye1, Abdoul Wakhabe Kane1, Henri Michel Benoist2 and
Pierre Farge3
1
Institute of Dentistry, Service of Conservative Dentistry and Endodontics; 2Service of Periodontics, Route de lUniversite, University Cheikh Anta
Diop, Dakar, Senegal; 3Faculty of Odontology, Department of Conservative Dentistry and Endodontics, University Claude Bernard Lyon 1, Lyon
Cedex, France.

Aim: To assess the effectiveness of mineral trioxide aggregate (MTA) used as an indirect pulp-capping material in human
molar and premolar teeth. Methodology: We conducted a clinical evaluation of 60 teeth, which underwent an indirect pulpcapping procedure with either MTA or calcium hydroxide cement (Dycal). Calcium hydroxide was compared with MTA and
the thickness of the newly formed dentine was measured at regular time intervals. The follow-up was at 3 and 6 months, and
dentine formation was monitored by radiological measurements on digitised images using Mesurim Pro software. Results: At 3 months, the clinical success rates of MTA and calcium hydroxide were 93% and 73%, respectively
(P = 0.02). At 6 months, the success rate was 89.6% with MTA, and remained steady at 73% with calcium hydroxide
(P = 0.63). The mean initial residual dentine thickness was 0.23 mm, and increased by 0.121 mm with MTA and by
0.136 mm with calcium hydroxide at 3 months. At 6 months, there was an increase of 0.235 mm with MTA and of 0.221 mm
with calcium hydroxide. Conclusions: A higher success rate was observed in the MTA group relative to the Dycal group
after 3 months, which was statistically significant. After 6 months, no statistically significant difference was found in the
dentine thickness between the two groups. Additional histological investigations are needed to support these findings.
Key words: Calcium hydroxide, dentine bridge, mineral trioxide aggregate, pulp capping, randomised controlled trial

INTRODUCTION
The consequences of pulp exposure from caries, trauma
or unexpected tooth preparation procedures can be
severe, with pain and infection. Pulp capping, in which
a medicament is placed directly over the exposed pulp
(direct pulp cap), or a cavity liner or sealer is placed
over residual caries (indirect pulp cap), is an attempt to
maintain pulp vitality and avoid more extensive
treatments1.
There are key procedures in the management of vital
teeth with deep carious lesions24, which can be
performed with high predictable long-term success
rates5.
Calcium hydroxide is the gold standard for pulp
capping, following the initial publication by Zander6 in
1939. It allows for the formation of a reparative dentine
bridge through cellular differentiation, extracellular
matrix secretion and subsequent mineralisation7,8.
2012 FDI World Dental Federation

From a clinical point of view, it enables successful

maintenance of pulp vitality2, protects the pulp against
thermoelectric stimuli and has an antimicrobial action.
Calcium hydroxide is used as a reference for other
capping agents, such as glass ionomer cement and
adhesives912.
However, in long-term clinical studies of pulp
capping with calcium hydroxide-based materials, failure rates increase with the follow-up time3. Known
disadvantages for this material include gradual degradation and tunnel defects in the newly formed dentine.
In addition, an increased frequency of inflammatory
cells and localised areas of pulp necrosis have been
reported over time1316.
Mineral trioxide aggregate (MTA) is a pulp-sealing
agent, essentially composed of a mixture of tricalcium
silicate, dicalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite and calcium sulphate dehydrate
which are the main components of Portland cement
33

Leye Benoist et al.

and 24.30 5.30 years for the MTA group. Thirty
teeth were considered for each material (Table 1).
The sample size was determined according to the
literature review and in order to yield statistically
significant results for the measurement of the thickness
of newly formed dentine in each group. No changes
occurred in the outcomes after the trial had commenced.
All the selected teeth presented an active deep carious
lesion on either the occlusal or proximal surface. Reversible
pulp inflammation was present in all cases, as demonstrated by the transient painful response to pulp testing.
Teeth with periodontal lesions, internal or external
root resorptions, and patients with systemic medical
conditions, were excluded from the study.
Patients were informed about the procedure and
provided written informed consent after the study had
been approved by the ethics commission of our
institution.
All procedures were performed by one of the
investigators in the study (FL) who is a qualified
endodontist at our institution.
Pulp vitality was tested by submitting the tooth to
thermal and electrical testing:
A cold stimulus was given by the use of ethyl
chloride
Electrical testing was carried out using an electric
pulp tester (Electric Pulp Tester Averon PT 2.0,
VEGA-PRO, Ekaterinburg, Russia).
These tests were carried out at baseline, before pulp
capping, and at the 3- and 6-month post-operative
follow-up visits.

with an addition of bismuth oxide in a 4 : 1 ratio for

radio-opacity properties17,18.
This bioactive silicate cement has been shown to be
an effective pulp-capping material in canine models and
in nonhuman primates19. The material appears to be
successful because of its small particle size, sealing
ability, alkaline pH when set and slow release of
calcium ions. Investigators have reported that MTA
induces pulp cell proliferation, cytokine release and
subsequent hard tissue formation with the synthesis of a
mineralised dentine interface similar to that of biological hydroxyapatite19.
Most of the investigations conducted on MTA have
involved the evaluation of the clinical and radiographic
outcomes of pulp-capping procedures in either human
primary20,21 or permanent20 teeth. Other human studies have reported histological observations of the pulpcapping procedure15,16,2224; their results confirm those
reported in animal models13,25,26.
Therefore, the capping ability of MTA is comparable
with that of calcium hydroxide, but few clinical studies
have evaluated both compounds simultaneously. For
this reason, we conducted a prospective evaluation with
both MTA and calcium hydroxide. The aim of this
study was to assess the effectiveness of the pulp-capping
materials by measuring the thickness of the newly
formed dentine.
MATERIALS AND METHODS
The study design was a single-blind clinical trial
realised in a sample of 60 paired permanent teeth (30
in each group) according to their type and site of caries.

Pulp-capping procedure
MTA(ProRoot; Dentsply Tulsa Dental, Tulsa, OK,
USA) and calcium hydroxide material (Dycal Ivory,
Dentsply Caulk, Dentsply, L.D. Caulk, Milford, DE,
USA) were used as pulp-capping agents.
The operative procedure was performed as follows:
After local peri-apical or intraligamentary anaesthesia of the tooth, rubber dam isolation was provided
and carious lesions were removed using a three-step

Selection criteria
The teeth were selected from patients, aged 16
34 years, attending the faculty clinic of the Department
of Dentistry, University Cheikh Anta Diop, Dakar,
Senegal. The descriptive characteristics of the sample
are given in Table 1. The mean age of the patients was
23.37 4.92 years for the calcium hydroxide group

Table 1 Distribution of teeth according to the age and gender of the subjects and the type of pulp-capping material
Capping material

MTA
Ca(OH)2

Gender

Female
Male
Total
Female
Male
Total

12
18
30
14
16
30

Age (years)

t-test*

t-test*

Mean

SD

Min.

Max.

P value

P value

22.75
23.78
23.37
23.43
25.06
24.30

5.74
4.43
4.92
3.857
6.34
5.30

16
16
16
16
16
16

34
32
34
30
34
34

0.58

0.48

0.39

MTA, mineral trioxide aggregate; SD, standard deviation.

*t-test between males and females in each pulp-capping material group.

t-test between males and females in the two pulp-capping material groups.
34

2012 FDI World Dental Federation

MTA versus calcium hydroxide in pulp capping

procedure: (i) high-speed carious enamel removal with
a round diamond bur; (ii) dentine mechanical curettage
with a low-speed powered tungsten carbide bur
(H1 314 014 or H1 314 012, Dentsply, Maillefer,
Tulsa, OK, USA); (iii) manual final dentine curettage
using a spoon excavator (no 49, 61 or 73, Dentsply,
Maillefer) making it possible to see the pulp by
transparency
MTA powder was mixed with sterile water in a
3 : 1 ratio, placed on the operative site with plastic
amalgam carrier-like instruments (MTA Gun) and
applied by light pressure with moist cotton pellets.
Hard-setting calcium hydroxide paste (Dycal) was
mixed according to the manufacturers instructions and
applied to the sites with ball-ended instruments. Glass
ionomer cement (GC Fuji IX, GC EUROPE, Leuven,
Belgium) was placed over both materials as a filling
material during the 6-month evaluation period of the
study. The final restoration was placed over the glass
ionomer after 6 months, with either amalgam or
composite following the study period
A simple randomisation was used with a single
sequence of random assignment, without any restriction.The first tooth was randomly assigned to MTA and
the 30 following cases were alternatively assigned to
either calcium hydroxide or MTA. Each tooth was
secondarily paired with a control case with the other
pulp-capping material. The two paired cases differed
only by the pulp-capping material (MTA or calcium
hydroxide) and were paired for the type of tooth
(premolar, molar), age range (as shown in Table 1) and
gender of the patient. Table 2 displays the tooth distribution and sites of the initial carious lesions. Occlusal
lesions represented 45% of the sample, and proximal
lesions made up 55%; upper premolars and first lower
molars accounted for 58% of the total treated teeth.
Clinical and radiographic follow-ups were carried
out at baseline, 3 and 6 months. The treatment was
considered to be clinically successful when the pulp
remained vital with a normal response to thermal and
electrical tests without signs of spontaneous pain. The
treatment was considered to be radiographically successful when the dentine bridge was present over the

lesion and no furcation radiolucency, periodontal

ligament space widening, internal or external root
resorptions were noted.
The study and recruitment of the patients were
carried out from 21 May 2007 to 31 December 2008;
the study was terminated 6 months later (June 2009)
following the last follow-up of the final patient.
Radiographic assessment of the dentine thickness
All measurements of dentine thickness were performed
with Mesurim Pro Software (J-F. Madre, Academy
of Amiens, Amiens, France). This software is intended
to collect data on digitised images (e.g. counting of
elements on an image, measurements of surface light or
length). A 1-mm FixottEverett grid (FixottEverett
X-Ray Grid Large Ea, Miltex Instrument Co, Inc.,
York, PA, USA) was used. The FixottEverett grid
(Figure 1) is a metallic incorporated device placed in
contact with the X-ray film during exposure, and
results in a grid of known size being imaged. It was used
for radiological scaling for standardised measurements
on the digitised images. All the radiographs were
subsequently scanned and transferred to the computer
for digital analysis.
Measurements on the digitised radiograph were
performed at baseline (after the indirect pulp-capping
procedure) and at 3 and 6 months. On each digitised
radiograph, the scale for the measurements was determined using the space between two lines of the grid,
which was assigned a value of 1 mm; the dentine
thickness on each film was measured with Mesurim
Pro software accordingly to this scale calculation. The
range of measurements was 10)3 mm.
The measurements on the digitised images were
performed by one investigator in this study (HMB)
who was blind to the clinical procedure and the nature
of the pulp-capping material.
Statistical analysis
Statistical analysis was performed using SPSS software
(version 11.0 for Windows, SPSS Inc., Chicago, IL,

Table 2 Distribution of teeth according to the site of caries

Tooth type

Site of caries
Occlusal
n

Upper premolar
Lower premolar
1st upper molar
1st lower molar
2nd or 3rd upper molar
2nd or 3rd lower molar
Total
2012 FDI World Dental Federation

2
0
2
14
5
4
27

Total

Mesio-occlusal
(%)

(3.33)
(0)
(3.33)
(23.33)
(8.33)
(6.66)
(45.0)

Disto-occlusal

(%)

(%)

2
0
5
1
0
2
10

(3.33)
(0)
(8.33)
(1.66)
(0)
(3.33)
(16.7)

14
2
2
2
0
3
23

(23.33)
(3.33)
(3.33)
(3.33)
(0)
(5.00)
(38.3)

(%)

18
2
9
17
5
9
(60)

(30.00)
(3.33)
(15.00)
(28.33)
(8.33)
(15.00)
(100)
35

Leye Benoist et al.

Randomized
(n = 60 teeth)

Allocated to mta group

n = 30

Allocated to calcium
hydroxide group
n = 30

3 months
lost to follow-up = 1
success = 28
fail = 1
analyzed = 30
none excluded

3 months
lost to follow-up = 4
success = 22
fail = 4
analyzed = 30
none excluded

6 months
lost to follow-up = 0
success = 27
fail due to lost of
restoration = 1
analyzed = 30
none excluded

6 months
lost to follow-up = 0
success = 22
fail = 0
analyzed = 30
none excluded

Figure 1. FixotEverett grid and intrabuccal radiographic lm.

RESULTS

Figure 2. Flow diagram of trial.

100

Positive vitality test

Negative vitality test

90
80
70
Percent

USA). Cohens kappa statistic test for qualitative

measurements was used to assess the reliability of
electrical pulp testing (K = 0.624, substantial agreement according to Landis and Koch27); it was also used
for the intra-class correlation coefficient (ICC) for the
reliability of the radiographic measurements employing
Mesurim Pro Software (quantitative) with two-way
random single measures (consistency based on absolute
agreement) [ICC = 0.722; confidence interval (CI),
0.575; 0.824; P < 0.001].
Losses to follow-up were analysed as intention to
treat, i.e. regarded as failures. Means and proportions
for personal characteristics and clinical parameters
were calculated for both groups. The significance of
any difference in the means was tested using Students ttest, and the significance of any difference in proportions was tested using Pearsons chi-squared test. The
relationship between the independent variables and the
pulp-capping outcomes, considered as a dependent
variable, was assessed using multivariate logistic regression analysis on subject-based data. The variables
which were statistically insignificant in univariate
analysis were not considered for further analysis.
Statistical significance was defined as P < 0.05.

60
50
40
30
20
10
0

93.1
89.6

73.3

73.3

26.7

26.7
10.4

6.9
MTA
Ca(OH)2
Success rate at 3 months

MTA
Ca(OH)2
Success rate at 6 months

Figure 3. Success rates at 3 and 6 months according to the

pulp-capping material.

with calcium hydroxide than with MTA, which was

statistically significant (P = 0.02). After 6 months, with
one additional failure in the MTA group, the difference
between the two groups was not significant (P = 0.63).

Failure and success rates

The failures were defined as negative pulp vitality tests
on examination. As illustrated in the flow diagram of
the trial (Figure 2), at 3 months, there were four
failures in the calcium hydroxide group and one in
the MTA group. One additional failure at 6 months
was found in the MTA group.
At 3 months, the success rate was 93.1% for MTA
and 73.3% for calcium hydroxide, whereas, at
6 months, it was 89.6% for MTA and remained
unchanged for calcium hydroxide (Figure 3). At
3 months, the rate of failure was four times greater
36

Newly formed dentine thickness

The average thicknesses of newly formed dentine at 3
and 6 months are shown in Table 3. Using Mesurim
Pro Software, at 3 months, the measurements were
0.121 0.050 mm in the MTA group and
0.136 0.060 mm in the calcium hydroxide group
(P = 0.380). At 6 months, the averages were 0.235
0.110 mm in the MTA group and 0.221 0.059 mm in
the calcium hydroxide group (P = 0.594). In each
group, the thickness of the dentine bridge at 6 months
was approximately two-fold higher than that at
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MTA versus calcium hydroxide in pulp capping

Table 3 Average thicknesses of tertiary dentine at 3
and 6 months according to the pulp-capping material
Pulp-capping
material
MTA
n
Mean (mm)
SD (mm)
Ca(OH)2
n
Mean (mm)
SD (mm)

Follow-up duration

t-test*

t-test

3 months

6 months

P value

P value

28
0.121
0.059

27
0.235
0.110

0.000

<0.0001

22
0.136
0.060

22
0.221
0.059

0.000

Table 5 Multivariate logistic regression analysis with

predictive factors as independent variables and pulpcapping outcome as dependent variable
Variable

SE

Disto-occlusal )2.123 0.724

caries
MTA
1.870 0.754

Significance Exp(B)
or OR

95% CI
Lower Upper

0.003

0.120

0.029

0.495

0.013

6.489

1.481 28.439

CI, confidence interval; MTA, mineral trioxide aggregate; OR, odds

ratio; SE, standard error.

MTA, mineral trioxide aggregate; SD, standard deviation.

*t-test between male and females in each pulp-capping material
group.

t-test between male and females in two pulp-capping material

groups.

3 months, with a statistically significant difference

(P < 0. 0001).

explanatory variable (P = 0.003). The final predictive

model showed that the success of the pulp-capping
procedure can be predicted up to 43.8% of times when
MTA is used, and that failure can be predicted up to
90.9% of times when the carious lesion is on the distoocclusal site of the tooth.

Statistical analysis

DISCUSSION

Logistic regression analysis was performed to obtain a

predictive model for the pulp-capping outcome. Univariate analysis of the personal characteristics and
clinical parameters showed that only the disto-occlusal
site of caries and the type of capping material may
affect the pulp-capping outcome (Table 4). Multivariate logistic regression analysis showed that only MTA
and the disto-occlusal site of caries (independent
variables) were predictive factors for the pulp-capping
outcome as dependent variable. The odds ratio (OR)
from the logistic regression showed the effects of the
selected independent variables (Table 5). The distoocclusal site appeared to be an unfavourable factor and
showed (B = )2.123) the strongest evidence as an

MTA, mineral trioxide aggregate.

This study was designed as a prospective, randomised,

paired clinical study. The patients were young, reflecting the youth of the Senegalese population, and the
recruitment of patients at our institution. With regard
to the operating protocol, we placed a glass ionomer
cement over the capping material, which was used as
restoration material during the time of the study; thus,
electrical pulp testing for vitality could be performed
accurately during the follow-up period. Following the
pulp-capping procedure, bacterial leakage through the
final restoration material is considered to be more
detrimental to the outcome than bacterial contamination at the time of treatment28. This finding underlines
the need for a good seal in the final restoration material
after the completion of the pulp-capping procedure. In
this study, failure occurred in one case in the MTA
group, because of the loss of the restoration material.
As MTA and calcium hydroxide can be distinguished
by the operator on performing the pulp-capping
procedure, a double-blind clinical trial could not be
performed here.
The success rates were comparable for MTA and
calcium hydroxide at 6 months, but they differed at
3 months. Thus, the critical period for the success of the
capping procedure seems to be within the first
3 months. When looking at these success rates, and
with regard to the potential toxic effects of the capping
materials, we considered, as reported by Pashley 29, that
there was no difference between direct and indirect
pulp capping for the restoration of deep cavities,
because of the fast increase in dentine permeability
near the pulp. In deep cavities with a residual thickness
of dentine of less than 0.5 mm, the number and size of
open tubuli are such that communication with the pulp
is comparable with that of a true pulp exposure 30.

2012 FDI World Dental Federation

37

Table 4 Univariate analysis of the effects of personal

characteristics and clinical parameters on the
pulp-capping outcome
Variable

Score

df

P value

Age
Gender
Tooth localisation
Tooth type
Upper premolar
Lower premolar
1st upper molar
1st lower molar
2nd or 3rd upper molar
2nd or 3rd lower molar
Site of caries
Occlusal
Mesio-occlusal
Disto-occlusal
Pulp-capping material
Ca(OH)2
MTA

0.179
0.302
0.075

1
1
1

0.672
0.582
0.785

4.156
0.752
1.310
0.091
1.983
0.107

1
1
1
1
1
1

0.041
0.386
0.252
0.762
0.159
0.744

3.526
1.705
8.539

1
1
1

0.060
0.192
0.003

5.455
5.455

1
1

0.020
0.020

Leye Benoist et al.

The 93% success rate at 3 months with MTA is in
accordance with the results obtained by Bogen et al.19
in a 9-year follow-up study of direct pulp capping
among 40 patients aged between 7 and 45 years; they
reported successful pulp capping in 49 of 53 teeth
(97.96%) on the basis of radiographic criteria,
subjective symptoms and cold testing of pulp vitality.
In another clinical and radiographic, 24-month, followup study of direct pulp capping on temporary molars,
Tuna and Olmez31 recorded good results for both MTA
and calcium hydroxide (up to 100%).
The good clinical success rates are related to the
thickness of the newly formed dentine. In a reference
study using calcium hydroxide, Stanley et al.32 showed
that the thickness of the dentine bridge did not exceed
250 lm after 66 days, and reached up to 0.5 mm after
200 days. In our study, average thicknesses of the
dentine bridge were two-fold lower than those estimated by Stanley et al. 32. This difference could be
related to direct or indirect capping and the assessment
of the newly formed dentine thickness. In addition, our
measurements were made radiographically at baseline,
3 and 6 months, whereas Stanley et al.32 measured
histological cuts of dentine formation. The thickness of
the newly formed dentine, using MTA as a pulpcapping material, was not documented. In this study,
we found a slower formation of the dentine bridge from
baseline to 3 months in the MTA group than in the
calcium hydroxide group. Between 3 and 6 months,
this difference was not maintained, and no difference
was found at 6 months. This could be explained by the
fact that MTA serves as a reservoir for calcium
hydroxide and the calcium release from MTA materials
decreases slightly over time1.
The clinical and radiographic data reported here may
be related to the cellular and biomechanical mechanisms of reparative dentine formation. Calcium
hydroxide promotes the dentine repair of pulp wounds,
and the presence of superficial pulp tissue necrosis is
crucial and serves as a stimulus for the initiation of the
hard tissue repair process2. Calcium hydroxide has the
ability to dissolve the dentine, and thus gradually
release growth factors33.
MTA does not contain calcium hydroxide but, after
hardening, calcium oxide is formed that can react with
tissue fluids to give calcium hydroxide18; this can
induce the secretion of fibronectin by the pulp cells
adjacent to the necrotic layer under the capping
material34. MTA is able to stimulate reparative dentine
formation by the stereotypic defensive mechanism of
early pulp wound healing26.
The liberation of dentine factors by MTA has been
demonstrated, but at different concentrations to those
released by calcium hydroxide35. These differences
could account for the different kinetics of dentine
formation in our study, and may lead to dentine bridges
38

of different quality; the quality of the newly formed

dentine is a significant factor for the success of the
capping procedure. Histological studies have shown a
greater frequency of inflammatory cells and zones of
pulp necrosis when calcium hydroxide is used for
capping1316,36. In vivo studies have shown that MTA
induces the formation of a high-quality thicker dentine
bridge15,16,37.
In this study, logistic regression analysis identified
two variables predictive of the capping outcome. In the
final predictive model, MTA was significantly predictive of the success of pulp capping and a disto-occlusal
site of caries significantly increased the risk of failure.
The difficult visual access and control of dentine
curettage in some areas of the teeth and the better
quality of the dentine bridge and sealing ability of MTA
support these findings13,15,16,37.
Other predictive models for pulp capping have
emphasised age as a dependent variable for success of
the procedure. This was not apparent in the logistic
regression analysis performed in this study, as the
sample population was homogeneous for age and
mainly involved young adults; these cases are easily
managed and inflammatory involvement is minimal, as
suggested by bleeding that is easy to stop 2.
Further clinical studies need to be performed on
a larger sample in order to check whether the
disto-occlusal site of caries is a predictive, and not
operator-dependent, factor. As no detrimental effect
was demonstrated with MTA, its use may appear to be
of long-term benefit. Further generalisability of these
results will require a larger sample and longer follow-up
duration.
CONCLUSION
Based on the results of this short-term clinical and
radiographic study, a higher success rate was observed
in the MTA group relative to the Dycal group after
3 months, which was statistically significant. After
6 months, however, no statistically significant difference was found in the dentine thickness between the
two groups. Additional histological investigations are
needed to support these findings.
Acknowledgements
The authors thank Dr Papa Ibrahima Ngom, Associate
Professor in Orthodontics at University Cheikh Anta
Diop, Dakar, Senegal, who performed statistical analysis, and Roland Arsan for the gracious provision of
products that enabled this study to be conducted.
Conflicts of interest
This study was not financed by any company or
manufacturer and has no commercial aim.
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MTA versus calcium hydroxide in pulp capping

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Correspondence to:
Dr Fatou Leye Benoist,
Institute of Dentistry,
Service of Conservative Dentistry and Endodontics,
University Cheikh Anta Diop,
Route de lUniversite, BP16014,
Dakar-Fann 12522, Dakar, Senegal.
Email: fatou.leye@ucad.edu.sn

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