Journal of Investigative and Clinical Dentistry (2015), 0, 115

REVIEW ARTICLE
Dental Biomaterials

Calcium silicate-based cements: composition, properties,

and clinical applications
Alaa E. Dawood, Peter Parashos, Rebecca H.K. Wong, Eric C. Reynolds & David J. Manton
Melbourne Dental School, Oral Health Cooperative Research Centre, University of Melbourne, Melbourne, Vic., Australia

Keywords Abstract
calcium silicate-based cement, clinical Mineral trioxide aggregate (MTA) is a calcium silicate-based cement (CSC)
applications, endodontic, mineral trioxide commonly used in endodontic procedures involving pulpal regeneration and
aggregate, properties.
hard tissue repair, such as pulp capping, pulpotomy, apexogenesis, apexifica-
Correspondence
tion, perforation repair, and root-end filling. Despite the superior laboratory
Professor David Manton, Melbourne Dental and clinical performance of MTA in comparison with previous endodontic
School, University of Melbourne, 720 repair cements, such as Ca(OH)2, MTA has poor handling properties and a
Swanston Street, Melbourne Vic. 3010, long setting time. New CSC have been commercially launched and marketed to
Australia. overcome the limitations of MTA. The aim of the present review was to
Tel: +61-03-93411493 explore the available literature on new CSC products, and to give evidence-
Fax: +61-03-93411595
based recommendations for the clinical use of these materials. Within the limi-
Email: djmanton@unimelb.edu.au
tations of the available data in the literature regarding the properties and
Received 20 May 2015; accepted 19 August performance of the new CSC, the newer products could be promising
2015. alternatives to MTA; however, further research is required to support this
assumption.
doi: 10.1111/jicd.12195

root repair material (Brasseler USA, Savannah, GA, USA),

Introduction
Calcium silicate-based cements (CSC), including mineral
trioxide aggregate (MTA), are self-setting hydraulic
cements.1 The powder of CSC is composed mainly of
dicalcium and tricalcium silicate. After mixing the powder
with water, Ca(OH)2 and calcium silicate hydrate are pro-
duced primarily, and the mix forms a sticky colloidal gel
(calcium silicate hydrate gel) that eventually solidifies to a
hard structure.2,3 Calcium silicate-based cements are used
commonly in endodontic procedures involving pulpal
regeneration and hard tissue repair, such as pulp capping,
pulpotomy, apexogenesis, apexification, perforation
repair, and root-end filling.4 The sealing ability and bio-
compatibility of CSC, in addition to physicochemical
interaction with the local environment, are believed to be
primary factors contributing to their suitability in the
aforementioned clinical situations.57 Biodentine (Septo-
dont, Saint Maur des Fosses, France), Bioaggregate (Inno-
vative Bioceramics, Vancouver, Canada), Endosequence
calcium-enriched mixture cement (BioniqueDent, Tehran,
Iran), and TheraCal (Bisco, Schamburg, IL, USA) are
new, commercially-available CSC. Their composition and
physical properties are outlined in Tables 1 and 2.
Mineral trioxide aggregate
Mineral trioxide aggregate is a bioactive cement originally
designed as an endodontic repair and root-end filling
material with favorable physical properties and setting
characteristics.8,9 The indications and clinical applications
for MTA have expanded considerably from its original
recommended uses.4 Recently, MTA has become a com-
mon substitute for Ca(OH)2, and the outcomes of the
available clinical studies comparing MTA with Ca(OH)2
indicate its superiority.10 The powder of MTA (a mixture
of a purified Portland cement and bismuth oxide) is com-
posed of fine hydrophilic particles that set on mixing with
water (Table 1).3,11

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Calcium silicate-based cements A. E. Dawood et al.

Table 1. Composition of calcium silicate-based cements

Cement Composition

MTA Powder Purified Portland cement (mixture of dicalcium silicate [Ca2SiO4], tricalcium silicate [Ca3SiO5], tricalcium aluminate
[Ca3Al2O6], calcium sulfate [CaSO4, gypsum], and tetracalcium aluminoferrite [4CaO!Al 2O 3Fe 2O 3]) and
bismuth oxide
Small quantities of SiO2, CaO, MgO, K2SO4, and Na2SO4
Liquid Distilled water
Biodentine Powder Tricalcium silicate (3CaO.SiO2), dicalcium silicate (2CaO.SiO2), calcium carbonate (CaCO3), calcium oxide (CaO),
and zirconium oxide (ZrO2) as a radiopacifier
Liquid Water, calcium chloride (CaCl2), Hydrosoluble polymer (Plasticizing agent)
Bioaggregate Powder Tricalcium silicate (Ca3SiO5), dicalcium silicate (Ca2SiO4), hydroxyapatite (Ca10[PO4]6[OH]2), calcium silicate oxide
(Ca3[SiO4]O), tantalum oxide (Ta2O5), calcium phosphate silicate (Ca2SiO40.5Ca3[PO4]2)
Liquid Distilled water
Endosequence root Ready-to-use paste or putty composed of calcium silicates (Ca2SiO4), monobasic calcium phosphate (Ca[H2PO4]2),
repair material zirconium oxide (ZrO2), tantalum oxide (Ta2O5), proprietary fillers, and thickening agents
Calcium-enriched Powder Calcium oxide (CaO), sulfur trioxide (SO3), phosphorous pentoxide (P2O5), silicon dioxide (SiO2)
mixture cement Trace amounts of aluminum trioxide (Al2O3), sodium oxide (Na2O), magnesium oxide (MgO), and chloride (Cl)
Liquid Distilled water
TheraCal Light cure paste consists of type III Portland cement, Sr glass, fumed silica, barium sulfate (BaSO4), barium
zirconate (BaZrO3), and resin-containing bisphenol A glycidyl methacrylate (Bis-GMA) and poly dimethacrylate
(PEGDMA)

Table 2. Physical properties of calcium silicate-based cements

Cement Setting time (min) Compressive strength (MPa) Surface microhardness (HV)

ProRoot MTA 165, 175* 40 (24-h storage) 37.5 (24-h storage)

67 (3 weeks storage)
Angelus MTA 24 46.4 (24-h storage) 32.7 (24-h storage)
65.1 (4-days storage)
Biodentine 6.545* 61.3, 78.5* (1-day storage) 45.4 (1-day storage)
48.4 (28-days storage)
62.6 (3- and 7-days storage)
67.2 (28-days storage)
Bioaggregate 240 17.7 (1-day storage) 10.7 (28-days storage)
20.5 (3-days storage)
22 (7-days storage)
16.3 (28-days storage)
Endosequence root repair material 162 4050 (7-days storage) 44.3, 48.5 (10-days wet storage)
31.7, 58.9 (10-days dry storage)
Calcium-enriched mixture cement 50 2.9 (manually mixed)
12.5 (amalgamator mixed)
(both 1-week storage)

*Different values reported by different studies.

Level of measurement is 2 mm from the proposed apex of an experimental apexification model.
Level of measurement is 4 mm from the proposed apex of an experimental apexification model.

setting time of less than 10 min, and a final setting time

Physical properties of mineral trioxide
aggregate
The setting of MTA takes a relatively long clinical, time
and is variable between studies and different brands. The
setting time of gray MTA varies between 2 h 45 min and
2 h 55 min, and white MTA sets in 2 h 20 min (white
and gray ProRoot MTA; Dentsply Tulsa Dental, Tulsa,
OK, USA).8,12 Angelus MTA (Angelus Industria de
Produtos Odontologicos, Londrina, Brazil) has an initial
of less than 24 min.13
Less than 3% weight loss has been reported after
immersing set MTA in water for 24 h.14 Twenty-four
hours after setting, MTA had a mean compressive
strength value of 40 MPa which was significantly lower
than silver amalgam and Intermediate Restorative Mate-
rial (IRM; L.D. Caulk, Milford, DE, USA), and Super
EBA cement (Harry J. Bosworth, Skokie, IL, USA). How-
ever, 3 weeks later, the compressive strength of MTA

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A. E. Dawood et al.
increased to 67 MPa (statistically significantly lower than
that of silver amalgam and IRM, but similar to that of
Super EBA) as MTA continues to mature for up to
1 year, although it is determined clinically to be set ear-
lier.8,15 The compressive strength of Angelus MTA was
46.4 MPa and 65.1 MPa after 24-h and 4-day storage,
respectively, in an aqueous environment at 37C.16,17 The
surface microhardness of ProRoot MTA and Angelus
MTA were 37.5 and 32.7 HV, respectively, after 24-h stor-
age.16,18
Sealing ability and bond strength of mineral
trioxide aggregate
Factors contributing to the push-out bond strength and
sealing ability of MTA are putatively a combination of
MTAdentine bond, setting expansion, and friction with
the dentinal surface.1921 It was reported that MTA with
setting accelerated by CaCl2 has higher push-out bond
strength.22 The addition of CaCl2 to Portland cement
powder significantly improved the push-out bond
strength, especially after immersion in solution containing
phosphate (PO43; Pi).19 The addition of CaCl2 to MTA
increases the release of calcium ions (Ca2+) which interact
with Pi from the tissue fluid to form calcium phosphate
salts that undergo hydration to hydroxyapatite-like pre-
cipitates.23,24 The apatite-like crystals precipitate at the
MTAdentine interface and within the dentine collagen
fibrils, producing chemical and mechanical bonds
between MTA and dentine, and improving the push-out
bond strength and sealing ability.19
Biological properties of mineral trioxide
aggregate
The physicochemical interaction of CSC with the environ-
ment is believed to be the primary factor that contributes
to the cements biocompatibility, dentinogenic activity,
and sealing ability.7,25 MTA biocompatibility is similar to
chemically-inert titanium and greater than silver amal-
gam, Super EBA, and IRM.26,27 After setting, MTA pro-
duces Portlandite (crystalline Ca[OH]2).2 Portland
cement and MTA are rich in CaO, and in the presence of
water, CaO + H2O ? Ca(OH)2.28 Alkaline pH levels and
Ca2+ in the fluid surrounding MTA are conducive to
hard-tissue precipitation.7 The Ca2+ released by MTA
enhances osteoblastic viability, proliferation, and differen-
tiation, and OH" increases the alkalinity of the environ-
ment, which is unfavorable for bacterial growth.29,30
Calcium silicate-based cements are active biomaterials;
that is, they have the ability to induce a favorable
response from the host tissues. When stored in simulated
extracellular tissue fluids enriched with Pi, such as phos-
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Calcium silicate-based cements
phate-buffered solutions (PBS), MTA forms calcium
phosphate salts and apatite precipitates on its surface.31,32
Clinical applications of mineral trioxide
aggregate
Many studies have shown successful clinical outcomes
with MTA used in direct pulp capping, pulpotomy, root-
end filling, apexification, and repair of perforations.3343
Limitations of mineral trioxide aggregate
There are several problems associated with the clinical use
of MTA, including poor handling properties, long setting
time, presence of toxic components in the cement com-
position, difficult retrieval from the treated area, post-
treatment tooth discoloration, and high cost.8,4448
MTA shares with Ca(OH)2 the mechanism of inducing
hard-tissue formation, which is known to cause inflam-
matory and necrotic changes in the subjacent pulp tis-
sue.49 MTA releases low levels of arsenic, as it has a
similar elemental composition to Portland cement.45
However, the total amount of arsenic released from all
MTA types, and even some types of Portland cement, is
miniscule, and is not a contraindication for their clinical
use.50
Retrieval of set MTA from within the root canal is dif-
ficult, as there is no known solvent.46 Moreover, MTA
use can lead to tooth discoloration.47,5154 Thus, the
development of non-toxic, biologically-active, and cheaper
endodontic repair cements with improved handling prop-
erties, shorter setting time, and minimal post-treatment
complications (such as discoloration) is warranted.
Biodentine
Biodentine is a fast-setting CSC manufactured specifically
as a dental material, and marketed commercially as a den-
tine substitute, a pulp-capping material, and for other
endodontic applications similar to those advocated for
MTA.55
Biodentine is sold as a capsulated powder and liquid in
a pipette (Table 1).55 The physical properties of Bioden-
tine are improved (compared with MTA) by the modifi-
cation of powder composition, the addition of setting
accelerators and softeners, along with a predosed capsule
formulation for use in a triturator, making it user-
friendly.56,57 The consistency of mixed Biodentine is simi-
lar to that of zinc phosphate cement.58 Biodentine can be
placed directly into the cavity in bulk with no dentine
pretreatment, setting approximately 12 min after mixing.
It is claimed that this reduction in setting time has been
achieved by increasing the specific surface size of the par-
3
Calcium silicate-based cements
ticles, the addition of a setting accelerator (CaCl2), and
decreasing the liquid component.55 Different setting times
have been reported for Biodentine (ranging from 6.5 min
to 45 min), which could be due to different test methods
and environments used.16,5962
Physical properties of Biodentine
The compressive strength and surface hardness of Bioden-
tine are higher than that of other CSC (MTA and Bioag-
gregate), attributed to the low water/powder ratio which
is possibly due to the presence of the water-soluble poly-
mer in the liquid.16,60,62 The compressive strength and
surface hardness of Biodentine have been reported to be
67.2 MPa and 48.4 HV, respectively, after 28 days storage
in an aqueous environment at 37C.62 In another study,
the compressive strength of Biodentine was 61.35 MPa
(after 1-d storage) and 62.6 MPa (after 3-d and 7-d stor-
age).60 Other researchers reported 78.5 MPa for the com-
pressive strength and 45.4 HV for the surface hardness
after 1-d storage.16 These variations among reported com-
pressive strength and surface hardness values of Bioden-
tine could be due to the different test environments and
storage periods used. The other physical properties of
Biodentine, such as flexural strength and elastic modulus,
are also higher than those of MTA and similar to dentine,
with Biodentine being denser and less porous than
MTA.63,64 Because of its susceptibility to abrasion, Bio-
dentine is considered a weak enamel substitute; however,
it can be used successfully as a permanent dentine substi-
tute under resin composite restorations and as a tempo-
rary restoration in posterior teeth for up to 6 months.65
The placement of resin composite restorations over Bio-
dentine should be delayed for 2 weeks to allow adequate
setting and maturation of Biodentine to withstand the
contraction forces of the resin composite.66
Sealing ability and bond strength of
Biodentine
The sealing ability of Biodentine at the cementdentine
interface in an open-sandwich restoration (in vitro) is
comparable to that of resin-modified glass ionomer
cement (GIC).67 The superior marginal integrity of Bio-
dentine-filled open-sandwich restorations is attributed to
the ability of CSC to promote the precipitation of apa-
tite-like crystals.68 As an active biomaterial, when Bioden-
tine comes in contact with Pi in vitro, precipitates develop
that resemble hydroxyapatite, and enhance the uptake of
Ca2+ and Si in the adjacent root canal dentine stored in
PBS.69 It has the ability to interact with dentine, forming
a mineralized interfacial zone, with tag-like structures
extending into the dentinal tubules.70,71 The Ca2+ release
4 2015 Wiley Publishing Asia Pty Ltd
A. E. Dawood et al.
and biomineralization ability of Biodentine are higher
than that of MTA.16,72,73 The push-out bond strength of
Biodentine to root dentine is also higher than that of
MTA.74
However, controversial findings about the sealing abil-
ity of Biodentine have been reported in vitro, and
acid-etched Biodentine has demonstrated structural and
chemical changes. Both acid-etched and unetched Bioden-
tine have demonstrated statistically-significant leakage at
the cementdentine interface compared with acid-etched
and unetched GIC when the materials were used as a base
under the resin composite.75
Biological properties of Biodentine
Biodentine is a highly-biocompatible, non-cytotoxic mate-
rial.60,76,77 Calcium silicate-based cements, such as Bio-
dentine and MTA, are rich in calcium compounds, and
an increase in Ca2+ release is known to stimulate hard-tis-
sue formation.78 The amount of Ca2+ released from Bio-
dentine and the depth of the incorporation of Ca2+ into
root canal dentine are greater than those for MTA.72 Pulp
cell differentiation into odontoblast-like cells is induced
by Biodentine in addition to mineralized tissue and repar-
ative dentine formation.79,80
The application of Biodentine onto exposed rat pulps
induced odontoblastic differentiation, and the dentine
bridge formed adjacent to Biodentine after 14 days and
30 days was similar to that formed by MTA.81 The use of
Biodentine as a direct pulp capping or pulpotomy mate-
rial in primary porcine teeth resulted in normal radicular
pulp tissue free from inflammation, along with a com-
plete dentine bridge (at the pulp exposure site) and thick
calcified tissue (at the pulpotomy site) after 90 days, with
no statistically-significant differences between Biodentine
and MTA.82 The formation of a thicker dentine bridge
was induced by Biodentine compared with MTA when
used as vital pulp therapy agents in dogs teeth.83 There
was no statistically-significant difference between the
responses of human pulp tissue to Biodentine and MTA
used as pulp-capping materials to cover iatrogenic pulp
exposure sites in intact human molars scheduled for
orthodontic extraction.58
Clinical applications of Biodentine
Biodentine can be used for vital pulp-capping procedures
and other endodontic applications that involve dentine
and cementum repair, and pulp regeneration.63 Deep
carious lesions, indirect pulp capping, direct pulp cap-
ping, and external root resorption have been successfully
treated using Biodentine.8487 Biodentine can be also used
as a permanent base material under resin composite and
A. E. Dawood et al.
as an intermediate restoration for up to 6 months.65 The
clinical success of Biodentine as an indirect pulp-capping
material was reported to be similar to that of GIC (Fuji
IX GP; GC, Alsip, IL, USA) after 12 months follow up;
however, the radiographic success was in favor of Bioden-
tine, as the majority of teeth with healed periapical lesions
were treated with Biodentine.87
The short setting time of Biodentine is a clinical advan-
tage over the other long setting-time CSC, especially in sit-
uations that warrant definitive treatment in a single visit,
such as in pediatric dentistry. Furthermore, an in vitro
GIC-loaded stainless steel crown can be placed over Bio-
dentine 3 min after mixing, without displacing the Bio-
dentine significantly.88
Because of its favorable physical properties, good han-
dling characteristics, short setting time, bioactivity,
biomineralization potential, sealing ability, and lower cost
than MTA, Biodentine could be an appropriate alternative
to MTA.
Bioaggregate
Bioaggregate is an endodontic repair CSC, which is con-
sidered a modified version of MTA.89 The manufacturer
claims that Bioaggregate was produced under controlled
conditions to create a contamination- and aluminum-free
ceramic biomaterial.90,91 Bioaggregate differs from MTA
due to the addition of tantalum oxide, instead of bismuth
oxide in MTA, for radiopacity.89,90 The components of
Bioaggregate are listed in Table 1.89,92
Bioaggregate is an aluminate-free, calcium silicate-based
material, with very low levels of trace element contamina-
tion.89,90,93 According to the manufacturers information,
the powder is mixed with deionized water for 25 min
(mixing and working time) before application.94 Complete
setting takes approximately 4 h (powder/liquid ratio = 1 g/
0.38 mL); therefore, it is recommended to place the perma-
nent restoration after at least 4 h, and this represents a clin-
ical disadvantage when the restoration is to be placed in a
single visit.95 Upon mixing the powder with the liquid
(deionized water), a nanocomposite network of calcium
silicate hydrate gel and Ca(OH)2 is formed.92 The calcium
silicate hydrate gel with the hydroxyapatite forms a fluid-
tight seal at the application site.91
Physical properties of Bioaggregate
Bioaggregate has significantly lower compressive strength
and surface microhardness compared with other
CSC.60,62,96 The compressive strength and surface hard-
ness of Bioaggregate were 16.3 MPa and 10.7 HV, respec-
tively, after 28-d storage in an aqueous environment at
37C.62 In another study, the compressive strength of
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Calcium silicate-based cements
Bioaggregate was 17.7, 20.5, and 22 MPa (after 1-, 3-,
and 7-d storage, respectively).60 When compared to MTA,
Bioaggregate is less resistant to cracking after exposure to
compressive forces.97 Therefore, Bioaggregate could be
less applicable in clinical situations where occlusal forces
are expected, such as vital pulp therapy and furcation
repair, subsequently limiting its clinical applicability.96
However, the strength of the cements used in vital pulp
therapy and furcation repair might be less important
because they are usually covered by a restorative material
having sufficient strength to withstand occlusal forces.
Sealing ability and bond strength of
Bioaggregate
The sealing ability of Bioaggregate is comparable to MTA
and higher than silver amalgam when used as a root-end
filling.98,99 The sealing ability of Bioaggregate is attributed
to the setting expansion accompanying the hydration pro-
cess and nano-sized particles (below 2 lm), which could
achieve good adhesion to root dentine.20,98,99
When placed in contact with a physiological solution,
Bioaggregate creates precipitates that resemble hydroxyap-
atite.92,100 The presence of calcium and phosphate in
Bioaggregate might play a role in its apatite-forming abil-
ity.101 In vitro, Bioaggregate also showed higher porosity
and fewer cracks at the cementdentine interface in com-
parison with Biodentine.102
However, the push-out bond strength values in furca-
tion perforations and root slices filled with Bioaggregate
were lower than those for MTA.101,103,104 Insignificant dif-
ferences between the push-out bond strength values, in
root slices filled with Bioaggregate and MTA, were also
reported.105 The push-out bond strength of Bioaggregate
was not affected by a low pH and thermocycling when
compared to MTA.101,104
Biological properties of Bioaggregate
Bioaggregate is a biocompatible and non-cytotoxic mate-
rial, with fewer systemic and local (subcutaneous inflam-
matory reaction) toxic effects compared with
MTA.60,106110 Bioaggregate has strong antibacterial and
antifungal properties (against Enterococcus faecalis and
Candida albicans, respectively), and hard tissue-forming
ability.106,111,112
An in vitro study showed that Bioaggregate has a simi-
lar ability as MTA to induce the differentiation of human
pulp cells into odontoblast-like cells and to stimulate
mineralized tissue formation.80,113 Bioaggregate has higher
mineralization ability and stimulates a higher expression
of odontoblastic differentiation-associated genes from
human dental pulp cells compared to MTA.108 Bioaggre-
5
Calcium silicate-based cements
gate enhances the expression of mineralization-associated
genes in osteoblast-like cells and periodontal ligament
fibroblasts.106,114
Clinical applications of Bioaggregate
Bioaggregate is indicated for root perforation repair, root
resorption repair, root-end filling, apexification, and pulp
capping.60,91,98,99,113,115
Although Bioaggregate has comparable biocompatibility
and sealing ability to MTA, along with hard tissue-
forming potential expected to be greater than MTA
because of the presence of Pi source in Bioaggregate, the
poorer mechanical properties and long setting time of
Bioaggregate limit the situations where it could replace
MTA.
Endosequence root repair material
According to the manufacturers information, Endose-
quence root repair material (ERRM) is a premixed CSC
that has been produced as a ready-to-use syringeable
paste or compactable putty with easier handling and
application compared to MTA.116 The components of
ERRM are listed in Table 1.117 The manufacturer claims
that the moisture present in the dentinal tubules is suffi-
cient for setting.
Physical properties of Endosequence root
repair material
ERRM is a radiopaque material with a setting time of 2
4 h (mean: 2.7 h).117,118 Increasing the environmental
moisture content increases the setting time and reduces
the microhardness of ERRM.119 When incubated at 37C
and 100% humidity, ERRM took 168 h to set.120 The
flow, dimensional change, solubility, and film thickness of
ERRM comply with the International Standards Organiza-
tion (ISO) specifications for dental root canal-sealing
materials, and this could indicate the appropriate clinical
behavior of ERRM as a root canal sealer.118 The strength
of ERRM is claimed by the manufacturer to be 70
90 MPa, although a compressive strength of approxi-
mately 4050 MPa (similar to MTA) has been
reported.121 The surface microhardness of ERRM in an
experimental apexification model was similar to Bioden-
tine and lower than MTA.122
Sealing ability and bond strength of
Endosequence root repair material
Nanosphere particles allow ERRM to enter the dentinal
tubules, and this, besides moistening the cement by den-
6 2015 Wiley Publishing Asia Pty Ltd
A. E. Dawood et al.
tine liquid, will create a mechanical bond with dentine
upon setting and limit the potential for shrinkage of the
material, creating dimensional stability.118,120,123 Marginal
adaptation (reflecting sealing ability) of ERRM used
in vitro as root-end filling was comparable to MTA.124,125
It was reported that ERRM had equivalent sealing ability
to MTA when the materials were used as root-end fillings
in vitro.126
When in contact with physiological solution, ERRM
creates hydroxyapatite-like precipitates.100,117 An alkaline
pH comparable to MTA is produced by ERRM and also
Ca2+ release, which could be conducive to hard-tissue
deposition.7,78,117,118,127 The push-out bond strength
of ERRM is equal to that of AH Plus sealer
(Dentsply, DeTrey, Konstanz, Germany), comparable with
MTA.128,129
Biological properties of Endosequence root
repair material
The biocompatibility of ERRM is similar to MTA when
material extracts were tested in vitro with human gingival
fibroblasts, mouse fibroblasts (L929), and human dermal
fibroblasts, as well as human periodontal ligament fibrob-
lasts and human osteoblasts.6,120,130133 Minimal cytotoxi-
city of ERRM is expressed on human osteoblast-like cells
(MG63), and the cytotoxicity and cytokine expressions in
response to ERRM were similar to those of MTA.134
However, in another study, ERRM reduced the viability
and alkaline phosphatase activity of human osteoblast-like
cells (Saos-2) compared to MTA, not affecting the viabil-
ity and alkaline phosphatase activity of the cells.135
Antibacterial properties of ERRM against Enterococcus fae-
calis are similar to MTA, attributed to high pH during
setting.136
Clinical applications of Endosequence root
repair material
Perforation repair, apical surgery, apical plug, and pulp
capping have been promoted as suitable uses for ERRM.91
As an alternative to MTA, ERRM could be suitable due
to ease of handling and application, as well as strength
and biological effect, similar to MTA. However, currently
there are insufficient in vitro and in vivo studies to sup-
port the use of this material.
Calcium-enriched mixture cement
Calcium-enriched mixture cement was introduced to den-
tistry in 2006 as a tooth-colored, water-based endodontic
repair cement with similar applications to MTA, but with
a different chemical composition.137139
A. E. Dawood et al.
Composition and setting of calcium-enriched
mixture cement
The powder of calcium-enriched mixture cement is com-
posed of several calcium compounds (Table 1).138 The
presence of phosphate in calcium-enriched mixture
cement is one of the major chemical differences compared
to MTA.139 The particle size of calcium-enriched mixture
cement powder is smaller than MTA, and this might con-
tribute to the better sealing ability of calcium-enriched
mixture cement, explaining the shorter setting time, better
flow, and reduced film thickness compared to MTA.138,140
When calcium-enriched mixture cement powder is
mixed with distilled deionized water, a hydration reaction
occurs producing a calcium- and phosphate-rich material
and soluble Ca(OH)2, subsequently resulting in the
release of Ca2+, Pi, and OH".138
Physical properties of calcium-enriched
mixture cement
The setting time of calcium-enriched mixture cement
(50 min) is shorter than that of MTA.138 The addition of
10% CaCl2 to calcium-enriched mixture cement reduced
the mean setting time from 58.3 to 33.3 min.141 The
working time, pH, and dimensional change of
calcium-enriched mixture cement are similar to MTA.138
Calcium-enriched mixture cement has more flow and
reduced film thickness compared to MTA.138 The com-
pressive strength of calcium-enriched mixture cement is
similar to that of Angelus MTA and lower than that of
ProRoot MTA and Biodentine.142 The compressive
strength of calcium-enriched mixture cement varied from
2.9 to 12.5 MPa, depending on the mixing method (man-
ual vs amalgamator); amalgamator use increased compres-
sive strength.143
Sealing ability and bond strength of calcium-
enriched mixture cement
The sealing ability of calcium-enriched mixture cement
is comparable to MTA, and unlike MTA, calcium-en-
riched mixture cement has the ability to form hydroxya-
patite-like precipitates after storage, even in normal
saline.144 Calcium-enriched mixture cement has the abil-
ity to release Ca2+, Pi, and OH", providing the basic
element for hydroxyapatite crystal formation.144,145 The
sealing ability of calcium-enriched mixture cement is
greater in PBS than in distilled water due to the pres-
ence of exogenous Pi, which could increase hydroxyap-
atite-like crystal formation.146 The push-out bond
strength of calcium-enriched mixture cement is lower
than that of MTA.147
2015 Wiley Publishing Asia Pty Ltd
Calcium silicate-based cements
Biological properties of calcium-enriched
mixture cement
The cytotoxicity of calcium-enriched mixture cement is
comparable with MTA.148,149 Calcium-enriched mixture
cement and MTA have a similar ability to induce
osteoblastic/odontoblastic differentiation, enhance the
expression of mineralization-related genes, promote den-
tine bridge formation in vital pulp, and stimulate cemen-
tum deposition when used as root-end filling
materials.150153 The biocompatibility and osteogenic
potential of calcium-enriched mixture cement is attribu-
ted to its ionic release.145,154
The antimicrobial activity of calcium-enriched mixture
cement against Enterococcus faecalis is comparable to Ca
(OH)2 and greater than MTA, because it contains more
potent bacterial inhibitors than CSC-based materi-
als.155,156 The antifungal effect of calcium-enriched mix-
ture cement is comparable to that of MTA.157
Clinical applications of calcium-enriched
mixture cement
Clinical reports recommend calcium-enriched mixture
cement for the treatment of internal and external root
resorption, apexification, apexogenesis, repair of furcation
perforation, root-end filling, direct pulp capping, and
pulpotomy in primary and permanent teeth.153,158166
Calcium-enriched mixture cement could also be used for
revascularization of necrotic immature permanent
molars.167
Calcium-enriched mixture cement and nano-hydroxya-
patite were compared as direct pulp capping materials in
sound human primary canines scheduled for orthodontic
extraction, with calcium-enriched mixture cement found
to be superior to nano-hydroxyapatite in terms of dentine
bridge formation and pulp health 2 months after applica-
tion.168 Clinical success of 100% and radiographic success
of 90% were reported with calcium-enriched mixture
cement used as a pulpotomy agent in human primary
molars after 24 months follow up, with the success rates
of electrosurgical pulpotomy being similar.169 When used
as a direct pulp-capping material in human primary
molars, calcium-enriched mixture cement demonstrated
no radiographic failures after 6 months follow up, with
clinical success rate of 94.8%.170 Similar outcomes were
achieved when calcium-enriched mixture cement and
MTA were used as pulpotomy agents to induce apexogen-
esis of immature carious lesion pulp-exposed permanent
molars (ages 610 years) after 12 months follow up.160
Randomized, clinical trials (1, 2, and 5 years) have indi-
cated the use of calcium-enriched mixture cement as a
vital pulp-therapy agent, and as an alternative to root
7
Calcium silicate-based cements
canal therapy for the treatment of mature permanent
molars with pulpitis.171173 Although calcium-enriched
mixture cement has a relatively long setting time, the
favorable clinical and biological outcomes make it appear
suitable as an endodontic repair cement; however, further
clinical research is required.
TheraCal
TheraCal is a radiopaque light-cure, resin-modified CSC,
promoted as a pulp-capping cement with an ability to
stimulate apatite-like precipitates and dentinal bridg-
ing.174176
Composition and setting of TheraCal
TheraCal paste consists of type III Portland cement,
strontium glass, fumed silica, barium sulfate (BaSO4),
barium zirconate (BaZrO3), and resin-containing Bis-
GMA and PEGDMA.174 Commercially available as a
ready-to-use flowable cement, TheraCal is dispensed via a
syringe, eliminating the need for mixing and handling
procedures, as the cement is applied directly onto the
operative site and light cured for 20 s for up to 1-mm
increments, according to the manufacturer instructions.177
A cure depth of 1.7 mm was reported for TheraCal.174
The polymerization of TheraCal is associated with low-
heat generation, and this could reduce adverse pulpal
effects when used in pulp-capping procedures.178 How-
ever, the presence of a resin monomer in TheraCal might
have adverse pulpal effects, considering that the interac-
tion of TheraCal with the pulp is not widely reported.
The hydration of the calcium silicate phase in TheraCal is
slower than Biodentine, triggered by environmental mois-
ture uptake.179,180 This could question the actual effect of
this phase in pulpal repair due to insufficient moisture
diffusion from the pulpdentine complex to the cement.
Physical properties of TheraCal
The solubility of TheraCal is lower than that of ProRoot
MTA, Angelus MTA, and Biodentine.174,175 The water
sorption and porosity of TheraCal are similar to ProRoot
MTA and Biodentine, and lower than Angelus MTA.175
Although the manufacturer claims high strength for Ther-
aCal, there are no published mechanical property data.
Sealing ability and bond strength of TheraCal
TheraCal has good sealing ability.174 The push-out bond
strength of TheraCal was lower than GIC and higher than
Biodentine and MTA in neutral and acidic environ-
ments.181 However, in an alkaline environment, the push-
8 2015 Wiley Publishing Asia Pty Ltd
A. E. Dawood et al.
out bond strength of TheraCal was lower than Biodentine
and higher than GIC and MTA.181 Compared to MTA,
TheraCal has higher bond strength compared to resin
composite.182
The bioactivity of TheraCal, represented by its ability
to induce the formation hydroxyapatite-like crystals in
simulated tissue fluid, was also reported, and this could
contribute to the chemical bond to dentine.175,179 How-
ever, TheraCal (as a resin-based cement) could depend
primarily on micromechanical bonding requiring acid
etching and bonding, not recommended in pulp capping
procedures.183 The shrinkage of the resin-based material
and subsequent bond failure could be another problem
with the use of this material.184
Biological properties of TheraCal
The ability of TheraCal to release high amounts of Ca2+
and its initial high alkalinity (pH 10 11) are primary fac-
tors contributing to the stimulation of hard tissue
repair.174,179,180 The Ca2+ released from TheraCal was
within the concentration range for stimulating hard tis-
sue-forming cells.29,174,185187 Released Ca2+ serves as a
bioactive signaling molecule, which promotes the process
of pulpal tissue repair.188 After 28 days, TheraCal induced
complete dentine bridge and mild inflammation when
used for direct pulp capping in primate teeth.176
TheraCal is well-tolerated by immortalized odonto-
blast-like cells; however, cellular proliferation induced by
TheraCal is lower than that of Biodentine and
MTA.189,190 TheraCal has antibacterial activity against
Streptococcus mutans lower than MTA and higher than
Biodentine.190
Clinical applications of TheraCal
The manufacturer recommends using TheraCal as direct
and indirect pulp capping material, and as a restorative
liner and base. As TheraCal is off-white in color, use as a
thin layer is recommended to avoid esthetic problems
and shading under resin composite restorations.191 Cur-
rently, there are insufficient in vitro and in vivo studies to
support the use of TheraCal.
Conclusion
Several new CSC have been launched commercially to
overcome the limitations of MTA. The newer products,
especially Biodentine, could be promising alternatives to
MTA; however, further research (especially to assess clini-
cal outcomes) is required. The reviewed CSC have similar
basic components and biological effects; however, they
differ from each other in their setting times and physical
A. E. Dawood et al.
properties, and these might be of less importance when research investigating clinical outcomes, place of the
the materials are used in non-stress-bearing areas and in application, strength of the cement, the initial strength
multiple-visit treatment. The decision to use a particular and type of the overlying restoration, and clinician prefer-
endodontic repair cement might depend on the quality of ence.
review. Dent Traumatol 2012; 28:
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