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. 2014 Jan 12;8(1):316–321. doi: 10.7860/JCDR/2014/7719.3980

[Table/Fig-2]:

Shows the summary of advantages and disadvantages of various pulp capping agents

Pulp capping agent Advantages Disadvantages
Ca (OH)2 (1960’s)

  • Gold standard of direct pulp capping material

  • Excellent antibacterial properties

  • Induction of mineralization

  • Low cytotoxicity

  • Highly soluble in oral fluids

  • Subject to dissolution over time

  • Extensive dentin formation obliterating the pulp chamber

  • Lack of adhesion

  • Degradation after acid etching

  • Presence of tunnels in reparative dentin
Zinc oxide eugenol cement (1960-70’s)

  • Reduces inflammation

  • Lack of calcific bridge formation

  • Releases eugenol in high concentration which is cytotoxic

  • Demonstrate interfacial leakage
Corticosteroids and antibiotics (1970’s)

  • Reduces pulp inflammation

  • Vanocmycin + Ca(OH)2 stimulated a more regular reparative dentin bridge.

  • Should not be used in patients at risk from bacteremia.
Polycarboxylate cement (1970’s)

  • Chemically bond to the tooth structure

  • Lack of antibacterial effect

  • Fail to stimulate calcific bridge formation
Inert materials (1970’s) (Isobutyl cyanoacrylate and Tri calcium phosphate ceramic)

  • Reduces pulp inflammation

  • Stimulate dentin bridge formation

  • None of these materials havebeen promoted to the dental profession as a viabletechnique
Collagen (1980)

  • Less irritating than

  • Ca (OH)2 and promotes mineralisation

  • Does not help in thick dentin bridge formation
Bonding agents (1995) 4-META-MMA-TBB adhesives and hybridizing dentin bonding agents

  • Superior adhesion to hard tissues

  • Effective seal against microleakage.

  • Have cytotoxic effect

  • Absence of calcific bridge formation

  • In vivo studies have demonstrated that the application of an adhesive resin directly onto a site of pulp exposure, or to a thin layer of dentin (less than 0.5 mm), causes dilatation and congestion of blood vessels as well as chronic inflammatory pulpal response
Calcium phosphate (1900’s)

  • Helps in bridge formation with no superficial tissue necrosis

  • significant absence of pulp inflammation compared to Ca(OH)2

  • Good physical properties

  • Clinical trials are necessary to evaluate this material
Hydroxyapatite (1995)

  • Biocompatible

  • Act as scaffold for the newly formed mineralized tissue

  • Mild inflammation with superficial necrosis of pulp
Lasers (1995-2010) CO2 Nd: YAG

  • Formation of secondary dentin

  • sterilization of targeted tissue

  • Bactericidal effects

  • Technique sensitive

  • Causes thermal damage to pulp in high doses

  • Technique sensitive

  • Causes thermal damage to pulp in high doses
Glass ionomer/Resin modified glass ionomer (1995)

  • Excellent bacterial seal

  • Fluoride release, coefficient of thermal expansion and modulus of elasticity similar to dentin

  • Bond to both enamel and dentin

  • Good biocompatibility

  • Causes chronic inflammation

  • Lack of dentin bridge formation

  • Cytotoxic when in direct cell contact

  • Poor physical properties, high solubility and slow setting rate

  • RMGIC is more cytotoxic than conventional GIC, so it should not be applied directly to the pulp tissue
Mineral trioxide aggregate (1996-2008)

  • Good biocompatibility

  • Less pulpal inflammation

  • More predictable hard tissue barrier formation in comparison to calcium hydroxide

  • Antibacterial property

  • Radiopacity

  • Releases bioactive dentin matrix proteins

  • More expensive

  • Poor handling characterstics

  • Long setting time

  • Grey MTA causes tooth discoloration

  • Two step procedure

  • High solubility
MTYA1-Ca (1999)

  • Helps in dentine bridge formation without formation of a necrotic layer

  • Shear bond strength is higher than conventional GIC and similar to RMGIC

  • Dentin bridge formation without reduction of pulp space in MTYA1-Ca, but there is reduction of pulp space is seen in dycal.

  • Better adhesion to dentine

  • Presence of 10% Ca(OH)2 interferes with complete curing of material, residual monomers causes cytotoxicity
Growthfactors (1900-2007) Bone Morphogenic Protein (BMP 2,4,7) Recombinant insulin like growth factor-I Other growth factors (1998) Epidermal growth factor Fibroblast growth factor Insulin like growth factor II Platelet-derived growth factor-BB TGF-β 1

  • Formation of osteodentin and tubular dentin

  • Formation of more homogeneous reparative dentin

  • Superior to Ca(OH)2 in the mineralization inducing properties

  • Dentin bridge formation was equal to dycal after 28 days

  • Only TGF-β1 induced reparative dentin formation

  • Possibility of unexpected side effects and the production

  • cost can be obstacles for their clinical application

  • Fail to stimulate reparative dentin in inflamed pulp

  • Half life is less

  • High concentration is required

  • Delivery vechicles used for the molecules show potent effects at the pictogram level and appropriate carriers will be required to facilitate their handling in the clinical situation

  • Appropriate dose response is required to avoid uncontrolled obliteration of pulp chamber

  • Possibility of immunological problems due to repeated implantation of active molecules

  • Other factors does not induced reparative dentin formation
Bonesialoprotein (2000)

  • Induced homogeneous and well mineralized reparative dentin

  • Superior to Ca(OH)2 in the mineralization inducing properties

  • Further clinical studies are needed
Biodentin (2000)

  • Biocompatible

  • Good antimicrobial activity.

  • Stimulate tertiary dentin formation

  • Stronger mechanically, less soluble and produces tighter seals compared to Ca(OH)2

  • Less setting time, good handling characteristics than MTA

  • More long-term

  • clinical studies are needed for a definitive evaluation of Biodentine
ENZYMES Heme-Oxygenase-1 (2008) Simvastatin (2009)

  • Play a cytoprotective role against pro inflammatory cytokines and nitric oxide in human pulp cells

  • Prevent H2O2 induced cytotoxicity and oxidative stress in human dental pulp cells.

  • Anti inflammatory action

  • Induction of angiogenesis

  • Improve the function of odontoblasts, thus leading to improved dentin formation

  • Further in vitro and in vivo studies are required

  • In high concentration causes pulp tissue damage.

  • Careful evaluation is required before clinical application to determine the suitable concentration when applied indirectly to a cavity or directly to pulp tissue.
STEM CELLS (2009) Dental pulp stem cells (DPSCs) Stem cells from human exfoliated deciduous teeth (SHED)

  • Regeneration of dentin-pulp complex

  • SHED is superior to DPSCs

  • Less economic

  • Technique sensitive
Propolis (2005-2010)

  • Antioxidant, antibacterial, antifungal, antiviral and anti-inflammatory properties

  • Superior bridge formation compared to Dycal, similar results to MTA

  • Forms dental pulp collagen, reduces both pulp inflammation and degeneration.

  • Stimulate reparative dentin formation

  • Showed mild / moderate inflammation after 2,4 weeks with partial dentinal bridge formation.
Novel endodontic cement (2010)

  • Biocompatible

  • Shorter setting time

  • Do not cause tooth staining

  • Good handling characteristics compared to MTA

  • Induced a thicker dentinal bridge with less pulp inflammation than MTA

  • Further assessment is required for evaluation of pulp response to this material in inflamed pulp.
Emdogain (2001-2011)

  • Promote odontoblast differentiation and reparative dentin formation

  • Suppresses the inflammatory cytokine production and create a favourable environment for promoting wound healing in the injured pulp tissues

  • Amount of hard tissue formed in EMD treated teeth was twice that of the calcium hydroxide

  • Post operative symptoms were less

  • MTA produced a better quality reparative hard tissue response with the adjunctive use of Emdogain compared with calcium hydroxide

  • EMD gel (EMD dissolved in propylene glycol alginate gel) when applied on exposed pulps without the adjunctive use of a pulp-capping material was proven to be ineffective in producing a hard tissue barrier because of its poor sealing qualities.

  • Clinical advantages of using EMD are unproven
Odontogenic ameloblast associated protein (2010)

  • Biocompatible

  • Accelerates reactionary dentin formation

  • Normal pulp tissue appearance withoutexcessive tertiary dentin formation and obliteration of the pulp cavity compared to MTA

  • Till now only in vitro study was conducted.

  • Further studies containing

  • a larger number of samples and longer follow-up assessments with various studies with higher primates should be followed
Endo sequence root repair material (2010-11)

  • Antibacterial property

  • Less cytotoxic than MTA, Dycal and light cure Ca(OH)2

  • Bioactivity of the cells as well as ALP activity were decreased gradually when exposed to ERRM
Castor oil bean cement (2010-11)

  • Good antibacterial property

  • Less cytotoxic

  • It showed less inflammatory response in subcutaneous tissue of rats when compared with calcium hydroxide cement.

  • Facilitates tissue healing

  • Better sealing ability than MTA & GIC

  • Good mechanical properties

  • Low cost

  • Bio inert rather than bioactive

  • Further clinical trials are required
Theracal (2012)

  • Act as protectant of the dental pulpal complex

  • Bond to deep moist dentin

  • Used as a replacement for Ca(OH)2, glass ionomer, RMGI, IRM/ZOE and other restorative materials

  • Have strong physical properties,no solubility, high radiopacity

  • TheraCal displayed higher calcium releasing ability and lower solubility than either ProRoot MTA or Dycal

  • It is opaque and “whitish” in color, it should be kept thin so as not to show through composite materials that are very translucent affecting final restoration shading