Clinical Research
Evaluation of Mineral Trioxide Aggregate and Calcium
Hydroxide Cement as Pulp-capping Agents in
Human Teeth
Maria de Lourdes R. Accorinte, DDS, MS, PhD,* Roberto Holland, DDS, MS, PhD,†
Alessandra Reis, DDS, PhD,‡§ Marcelo C. Bortoluzzi, DDS, PhD,‡
Sueli S. Murata, DDS, MS, PhD,† Eloy Dezan, Jr, DDS, MS, PhD,† Valdir Souza, DDS, MS, PhD,†
and Loguercio Dourado Alessandro, PhD‡§
Abstract
This study evaluated the histomorphologic response of
human dental pulps capped with mineral trioxide ag-
gregate (MTA) and Ca(OH)2 cement (CH). Pulp expo-
sures were performed on the occlusal floor of 40 human
permanent premolars. After that, the pulp was capped
either with CH or MTA and restored with composite
resin. After 30 and 60 days, teeth were extracted and
processed for histologic exam and categorized in a
histologic score system. The data were subjected to
Kruskal-Wallis and Conover tests (␣ ⫽ .05). All groups
performed well in terms of hard tissue bridge forma-
tion, inflammatory response, and other pulpal findings.
However, a lower response of CH30 was observed for
the dentin bridge formation, when compared with
MTA30 and MTA60 groups. Although the pulp healing
with calcium hydroxide was slower than that of MTA,
both materials were successful for pulp capping in
human teeth. (J Endod 2008;34:1– 6)
Key Words
Biocompatibility, calcium hydroxide, human pulp, min-
eral trioxide aggregate, pulp capping, pulp therapy
From the *Department of Dental Materials, School of
Dentistry, University Brás Cubas, São Paulo, SP, Brazil; †De-
partment of Endodontics, School of Dentistry, São Paulo State
University, UNESP-Araçatuba, São Paulo, SP, Brazil; ‡Dental
Materials and Operative Dentistry, School of Dentistry, Uni-
versity of Oeste de Santa Catarina, Joaçaba, SC, Brazil; and
§
Dental Materials and Operative Dentistry, School of Dentistry,
University of Ponta Grossa, PR, Brazil.
Address requests for reprints to Dr Alessandro Dourado
Loguercio, Universidade do Oeste de Santa Catarina, Facul-
dade de Odontologia, Av Getúlio Vargas, 2225, Bairro Flor da
Serra, 89600-000, Joaçaba, SC, Brazil. E-mail address:
aloguercio@hotmail.com.
0099-2399/$0 - see front matter
Copyright © 2008 by the American Association of
Endodontists.
doi:10.1016/j.joen.2007.09.012
JOE — Volume 34, Number 1, January 2008
T he aim of conservative pulp therapy is to maintain the coronal and radicular pulp
tissue in a viable condition. To accomplish this goal, living pulp tissue exposed to the
oral environment should be protected to preserve its vitality (1). Many studies indicated
that calcium hydroxide and calcium hydroxide compounds are the gold standard in
human teeth (2– 4), against which new materials should be tested.
However, several disadvantages have been listed with the use of calcium hydroxide
material. Presence of tunnels in dentin barrier, extensive dentin formation obliterating
the pulp chamber, high solubility in oral fluids, and lack of adhesion and degradation
after acid etching are some of the limitations reported (5–7).
Because of the aforementioned disadvantages, a variety of materials have been
proposed as candidates for direct pulp capping during recent years such as mineral
trioxide aggregate (MTA). Initially, MTA was used in endodontics to seal off all pathways
of communication between the root canal system and the external surface of the tooth
(8). Pitt Ford et al. (9) were the first to evaluate the performance of MTA for pulp
capping in monkey’s teeth, and they demonstrated superior performance of MTA com-
pared with calcium hydroxide. After testing both materials in dogs’ pulp, Faraco and
Holland (10) showed that MTA achieved the most favorable results.
Although several case reports and clinical studies have evaluated the effect of MTA
for pulp capping in permanent human teeth (11, 12), few histologic studies have been
conducted to evaluate the histologic response of MTA in human teeth (13, 14). In a
recent literature review, Roberts et al. (15) reported that there are still insufficient
clinical studies evaluating the performance of MTA for pulp capping.
Therefore, the purpose of this clinical study was to compare the histomorphologic
features of MTA and calcium hydroxide cement after 30 and 60 days. The null hypothesis
to be tested was that no significant difference will be observed in pulps capped with MTA
and calcium hydroxide during the 2 periods of evaluation.
Materials and Methods
Forty healthy human premolars scheduled to be extracted for orthodontic reasons
were selected from patients ranging from 15–30 years old. All teeth were examined
clinically and radiographically to ensure absence of proximal caries and periapical
lesions. The patients and/or their parents signed consent forms after receiving a detailed
explanation about the experimental rationale, clinical procedures, and possible risks.
The parents and the adult volunteers were asked to read and sign a consent form
allowing the clinical procedure. Both the consent form and the research protocol were
reviewed and approved by the Human Subject Review Committee from the University of
Oeste of Santa Catarina, SC, Brazil.
The vitality of all teeth was tested with thermal testing. ENDO-ICE frozen gas
(Coltène/Whaledent Inc, Mahwah, NJ) was applied for 5 seconds on the buccal surface
of the teeth scheduled for the pulp therapy and adjacent teeth. After local anesthesia
(Citanest 3%; Merrel Lepetit, São Paulo, Brazil) the rubber dam isolation was installed,
and each tooth was pumiced with a rubber cup at low speed. Occlusal cavities were
prepared by means of sterile diamond burs (#1095; KG Sorensen, Barueri, São Paulo,
Brazil) at high speed under water/spray coolant. The dimensions of the cavity were
MTA and Calcium Hydroxide Cement as Pulp-capping Agents 1
Clinical Research
Figure 1. Experimental design.
occlusal depth, 3.0 ⫾ 0.2 mm; mesiodistal width, 4.0 ⫾ 0.5 mm; and
faciolingual width, 3.0 ⫾ 0.2 mm. The cavity dimensions were checked
with a digital caliper in an attempt to standardize the cavity size. Pulp
exposure was performed in the center of the pulpal floor by means of a
round diamond bur under water cooling (#1014, ␾ 1.2; KG Sorensen).
One bur was used for each cavity. The teeth were then divided into 4
experimental groups (n ⫽ 10).
Homeostasis was established with a sterile cotton pellet soaked in
saline solution. In groups 1 (CH30) and 2 (CH60), calcium hydroxide
cement (Life, Kerr, Romulus, MI) was applied in the occlusal floor. In
groups 3 (MTA30) and 4 (MTA60), MTA (Dentsply Caulk, Milford, DE)
was applied in the occlusal floor (Fig. 1). After that, a thin layer of
resin-modified glass ionomer cement (Vitrebond; 3MESPE, St Paul,
MN) was applied. A total of 10 teeth were used for each experimental
condition.
Scotchbond Multi Purpose Plus (3M ESPE, St Paul, MN), a 3-step,
etch-and-rinse adhesive system, was used for all groups. Enamel and
dentin were conditioned with 35% phosphoric acid for 20 seconds. The
TABLE 1. Scores Used during Histologic Exams: Hard Tissue Bridge
Scores Continuity
1 Complete
2 Little communication of the capping material with
dental pulp
3 Only lateral deposition of hard tissue on the walls of
the cavity of pulp exposition
4 Absence of hard tissue bridge and absence of lateral
deposition of hard tissue
Scores Morphology
1 Dentin or dentin associated an irregular hard tissue
2 Only irregular hard tissue deposition
3 Only a slight layer of hard tissue deposition
4 No hard tissue deposition
Scores Thickness*
1 Up to 250 ␮m
2 150–249 ␮m
3 1–149 ␮m
4 Partial or absent bridge
Scores Localization
1 Closure to the exposition area without invading the
pulp space
2 Bridge invading pulp space next to the opposite
dentin wall
3 Bridge reached the opposite dentin wall
4 No bridge or only hard tissue deposition on the
walls of the exposition cavity
*Evaluated with a micrometric ocular in 3 different points of the bridge.
2 Accorinte et al.
acidic agent was rinsed out, and the dentin was slightly dried in such way
that the surface stayed visibly moist with a shiny appearance. One coat of
the primer was applied and air-dried for 20 seconds. The bonding resin
was subsequently applied and light-cured for 10 seconds. Increments of
Z-100 (3M ESPE) were used to restore the cavities. Each increment
(⫾2 mm) was light-cured for 40 seconds at 450 mW/cm2 (Ultralux
electronic; Dabi Atlante, Ribeirão Preto, SP, Brazil). A radiometer
(Model 100P; Demetron Research Corp, Kerr, Danbury, CT) was
used to check the light intensity immediately before each clinical
appointment. When necessary, the material excesses were removed
by using an ultra-fine diamond bur at high speed under water cool-
ing (KG Sorensen).
Teeth from groups 1 and 3 were extracted after 30 days, whereas
teeth from groups 2 and 4 were extracted after 60 days. The patients
were asked about the presence or absence of postoperative sensitivity
after 30 and 60 days. The extraction was performed under local anes-
thesia. The apical third of all roots was sectioned in 5 mm to facilitate
fixation in 10% buffered formalin solution for 72 hours. The teeth were
decalcified in 50% formic acid–sodium citrate for 6 – 8 weeks, pre-
pared according to normal histologic techniques and embedded in
paraffin. Six-micrometer-thick sections were cut with a microtome par-
allel to the main vertical axis of the tooth. The number of sections
obtained per tooth was not fixed. On the average, 10 –12 slides contain-
TABLE 2. Scores Used during Histologic Exams of Dental Pulp: Inflammatory
Response
Intensity of inflammatory reaction* (acute and
Scores
chronic processes)
1 Absent or very few inflammatory cells
2 Mild: average number less than 10 inflammatory cells
3 Moderate: average number 10-25 inflammatory cells
4 Severe: average number greater than 25
inflammatory cells
Extension of the inflammatory reaction (acute and
Scores
chronic processes)
1 Absent
2 Mild: inflammatory cells only next to dentin bridge
or area of pulp exposition
3 Moderate: inflammatory cells are observed in part of
coronal pulp
4 Severe: all coronal pulp is infiltrated or necrotic
Scores General state of the pulp
1 No inflammatory reaction
2 With inflammatory reaction
3 Abscess
4 Necrosis
*Evaluated in different areas with a magnification of 400⫻.
JOE — Volume 34, Number 1, January 2008

TABLE 3. Scores Used during Histologic Exams of Dental Pulp: Other Pulpal
Findings
Scores Giant cells
1 Absent
2 Mild
3 Moderate
4 Pulp necrosis
Scores Particles of capping materials
1 Absent
2 Mild
3 Moderate
4 Large number
Scores Presence of microorganisms
1 Absent
4 Present
ing 4 –5 six-micrometer-thick sections were obtained. The sections,
mounted on glass slides, were stained with hematoxylin-eosin. Brown
and Brenn technique was used to evaluate the presence of bacteria.
The sections were blindly evaluated by an experienced and cali-
brated pathologist according to the criteria described in Tables 1, 2, and 3
(1). Regarding inflammatory response of dental pulp, the area of count-
ing the cells was near the exposure pulp and capping material. Each
histomorphologic event was evaluated in a 1– 4 score system, with 1
being the best result and 4 the worst result. The multiple sections were
used to achieve an overall assessment for each tooth.
The scores attributed to each group were subjected to nonpara-
metric Kruskal-Wallis analysis. This test was performed separately for
each histologic exam (hard tissue bridge, inflammatory response of
dental pulp and general state of the pulp, and other pulpal findings)
(Tables 1, 2, and 3). The comparisons between averages were per-
formed by comparing the ranks with appropriately computed critical
values (␣ ⫽ .05) by using the Conover U test. This test is considered
very powerful for several independent samples (16).
Results
The percentage of scores for each group is shown in Tables 4, 5,
and 6. All groups performed well in terms of hard tissue bridge forma-
tion, inflammatory response, and other pulpal findings. However, an
inferior response of group CH30 was observed for the hard tissue bridge
formation, when compared with MTA30 and MTA60 groups (Table 4)
(P ⬍ .05). In other pulpal findings, CH30 was also inferior to MTA30
(P ⬍ .05), particularly as a result of the high percentage of calcium
hydroxide particles inside the pulp tissue (Table 6). No postoperative
sensitivity was reported by patients throughout the study period.
Clinical Research
Histomorphologic Features
Group CH30
Sixty percent of the specimens exhibited either total (20%) or
partial (40%) dentin bridge formation (Fig. 2A and B). No hard tissue
bridge was observed in 40% of the cases. In these cases, a chronic
inflammatory infiltrate was observed in the pulp tissue near capping
material or hard tissue bridge (Fig. 2B). In 70% of the cases, little
black-colored particles of Ca(OH)2 surrounded by macrophages were
found. In 10% of the specimens, gram-negative microorganisms were
observed, probably as a result of coronal infiltration. In these cases, no
hard bridge formation occurred, and there was an acute and chronic
inflammatory infiltrate.
Group CH60
Sixty percent of the specimens exhibited completely hard tissue
bridges, and in 30% of the cases, hard tissue bridge was partial (Fig.
2C). Only in 10% of the cases, no hard tissue bridge was formed. The
hard tissue bridge was usually thin and near to the exposure site (70%),
with aspect of normal pulp (Fig. 2C and D). In 60% of the specimens, a
chronic inflammatory infiltrate was observed, whereas in 40% of the
sample no inflammatory infiltrate was observed. Presence of the cap-
ping material associated to macrophages was observed in 60% of the
specimens. Giant cells were present in 10% of the cases, and no micro-
organisms were found in this group.
Group MTA30
Thirty percent of the specimens exhibited completely hard tissue
bridges, and in 70% of the cases, the hard tissue bridges were partial
(Fig. 2E and F). In 70% of the specimens, a chronic inflammatory
infiltrate with different intensities and extensions was observed (Fig.
2F), and only in 10% of the cases there was an acute inflammatory
infiltrate (Fig. 2E). Presence of capping particles or dentin fragments
was observed in 20% of the specimens (Fig. 2F). Giant cells and micro-
organisms were not detected in this group.
Group MTA60
Fifty percent of the specimens exhibited complete hard tissue
bridges (Fig. 2G and H), and in 40% of the specimens the hard tissue
bridges were partial, and the capping material communicated with the
pulpal tissue. No hard tissue bridge was observed in 10% of the speci-
mens. The hard tissue bridge was usually thin (70%) and near to the
exposure site (70%). In 80% of the specimens, a chronic inflammatory
infiltrate was observed (Fig. 2G). Presence of the capping material
associated to macrophages and particles of capping material inside
pulpal tissue were rarely found. In 10% of the specimens, gram-negative
microorganisms were observed, probably as a result of coronal infil-
tration or failure in the seal provided by the rubber dam isolation.

TABLE 4. Percentage of Scores (%) Attributed for Each Group in Each Criterion of Hard Tissue Bridge as Well as Multiple Comparisons
Continuity Morphology Thickness Localization
Groups * * * * †
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
CH30 20 40 — 40 2.6 60 — — 40 2.2 — — 60 40 3.4 60 — — 40 2.2 2.6 b
CH60 60 10 20 10 1.8 60 10 — 30 2.0 20 — 50 30 2.9 40 30 — 30 2.2 2.2 a,b
MTA30 30 60 10 — 1.8 70 20 10 — 1.4 — 10 80 10 3.0 90 — — 10 1.3 1.9 a
MTA60 50 20 20 10 1.9 60 30 — 10 1.6 30 — 50 20 2.6 70 10 — 20 1.7 2.0 a
Different superscripted letters indicate significant differences (P ⬍ .05).
*Means for each group in each subitem of the criteria of hard tissue bridge.
†Overall means for the criteria.

JOE — Volume 34, Number 1, January 2008 MTA and Calcium Hydroxide Cement as Pulp-capping Agents 3
Clinical Research
TABLE 5. Percentage of Scores (%) Attributed for Each Group in Each Criterion of Dental Pulp as Well as Multiple Comparisons
Acute inflammation Chronic inflammation General state of
Groups Intensity Extension Intensity Extension pulp †
* * * *
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 *
CH30 80 10 10 — 1.3 80 20 — — 1.2 10 60 20 10 2.2 10 60 20 10 2.3 10 90 — — 1.9 1.8 a
CH60 80 10 10 — 1.3 80 20 — — 1.2 10 60 20 10 2.3 10 60 20 10 2.3 40 60 — — 1.6 1.7 a
MTA30 90 10 — — 1.1 90 10 — — 1.1 30 50 10 10 2.0 30 30 40 — 2.1 30 70 — — 1.7 1.6 a
MTA60 80 — — 20 1.6 80 — 10 10 1.5 20 60 10 10 2.1 20 60 10 10 2.1 20 60 10 10 2.1 1.9 a
Different superscripted letters indicate significant differences (P ⬍ .05).
*Means for each group in each subitem of the criteria.
†Overall means for the criteria.

Discussion
If we consider the formation of complete or partial hard tissue
bridge, with no or little communication between capping material and
dental pulp as clinical success of pulp capping (13, 14), we can ensure
that all groups achieved pulp healing, because in most of the teeth either
a complete or partial hard tissue bridge was formed.
Although the exact mechanism by which MTA induces hard tissue
bridge formation is not completely understood, there are indications
that the mechanism of initiation of reparative dentinogenesis in capping
with MTA and Ca(OH)2 cement is similar (10, 17).
Tziafas et al. (17) observed a homogenous zone of crystalline struc-
tures that was initially found along the pulp-MTA interface, whereas pulp
cells, showing changes in their cytologic and functional state, were arranged
in close proximity to the crystals. Although MTA does not contain calcium
hydroxide, calcium oxide is formed after MTA hardening, which can react
with tissue fluids to produce calcium hydroxide (18). According to Seux et
al. (19), after contact with pulp tissue, MTA presents some structures that
are similar to calcite crystals found in calcium hydroxide. They attract fi-
bronectin, which is generally responsible for cellular adhesion and differ-
entiation, as do calcium hydroxide.
According to Faraco and Holland (10), the presence of necrotic
tissue nearest to the hard tissue bridge suggests that MTA, similar to
calcium hydroxide, initially causes necrosis by coagulation in contact
with pulp connective tissue. This reaction might occur because of the
high alkalinity of the product, whose pH is near to 9 –10 (20, 21).
Recently, Min et al. (22) compared the cellular effects of Portland
cement (the base of MTA) with other materials, including calcium hy-
droxide cement, on cultured human pulp cells. The results suggested
that Portland cement is biocompatible and allows the expression of
mineralization-related genes on cultured human pulp cells. These genes
are responsible for inductive process on hard tissue bridge formation
with MTA cement.
Despite the similarity in the responses of MTA and calcium hydroxide,
one cannot deny that a faster hard tissue bridge formation occurred when
MTA was used. A significant difference was observed between MTA and
calcium hydroxide after 30 days. Thus, it seems that MTA takes advantage in
producing healing in a shorter period of time (9), because in the 60-day
evaluation both pulp-capping agents yielded similar results.
This finding corroborates with previous studies conducted in an-
imals (9, 10). On the other hand, Iwamoto et al. (14) reported no
significant difference between MTA and calcium hydroxide regarding
hard tissue bridge formation or inflammatory cell response. Whereas
Iwamoto et al. (14) used white MTA, the present investigation used the
grey one. The composition of both materials is rather different. A sig-
nificantly higher amount of iron is present in the grey MTA compared
with the white, besides the fact that the latter does not contain aluminum
and dicalcium silicate (23, 24). Although one study has demonstrated
that the white MTA is not as biocompatible as the grey version (25), no
significant difference was observed between both MTA versions when
used for pulp capping (14). Thus, this matter still deserves further
evaluations to elucidate the concerns raised.
Another finding that deserves attention is the fact that in 70% of the
cases, little black-colored particles of Ca(OH)2 surrounded by macro-
phages were found in the calcium hydroxide group after 30 days, which
was not observed in the MTA groups. Because these particles might
induce calcification similar to what occurs with dentin chips, their pres-
ence could have been responsible for retarding the healing process
of Ca(OH)2, although controversy exists as to whether these parti-
cles that have been accidentally forced into the pulp promote or
retard healing (26).
No significant difference regarding the presence of microorgan-
isms was found among the groups evaluated. This means that the bac-
teriostatic action of calcium hydroxide and MTA per se (27–29) was
enough to reduce the number of viable bacteria near the pulp exposure.
On the other hand, the low sensibility of the histochemical staining
technique for the detection of bacteria makes their identification diffi-
cult, mainly when there is a small number of such microorganisms
(21). Moreover, bacteria are easily removed from dental tissue during
histologic preparation (30, 31).

TABLE 6. Percentage of Scores (%) Attributed for Each Group in Each Criterion of Other Pulpal Findings as Well as Multiple Comparisons
Particles of capping Presence of
Giant cells
Groups * materials * microorganisms * †
1 2 3 4 1 2 3 4 1 4
CH30 90 10 — — 1.1 30 50 10 10 2.0 90 — — 10 1.3 1.5 b
CH60 90 10 — — 1.1 40 50 10 — 1.7 100 — — — 1.0 1.3 a,b
MTA30 100 — — — 1.0 80 20 — — 1.2 100 — — — 1.0 1.1 a
MTA60 90 — — 10 1.3 80 10 — 10 1.4 90 — — 10 1.3 1.3 a,b
Different superscripted letters indicate significant differences (P ⬍ .05).
*Means for each group in each subitem of the criteria.
†Overall means for the criteria.

4 Accorinte et al. JOE — Volume 34, Number 1, January 2008


Figure 2. (A) Ca(OH)2, 30 days. Incomplete hard tissue bridge is shown. Ob-
serve that the hard tissue bridge is near dentin (white arrows), and there is an
intense and acute inflammatory infiltrate with different intensity and extension
below the hard tissue bridge (hematoxylin-eosin; original magnification, 40⫻).
(B) Ca(OH)2, 30 days. Higher magnification of (A). No hard tissue bridge was
formed in the the center of the exposure site. There is also no contact between
calcium hydroxide cement (above) and the pulp tissue (below) (white arrow).
One can also observe an intense and acute inflammatory infiltrate with hyper-
emic vessels (black arrow) (hematoxylin-eosin; original magnification,
100⫻). (C) Ca(OH)2, 60 days. There is a partial, irregular, and thin hard tissue
bridge with a communication of the capping material with dental pulp (white
arrow) (hematoxylin-eosin; original magnification, 40⫻). (D) Ca(OH)2, 60
days. Higher magnification of (C). Observe a partial hard tissue bridge with a
communication of the capping material in same points ( black arrow). Observe
a chronic inflammatory infiltrate with different intensity and extension (hema-
toxylin-eosin; original magnification, 100⫻). (E) MTA, 30 days. There is a
complete and irregular hard tissue bridge (white arrow). Observe irregular
hard tissue bridge and chronic inflammatory infiltrate with different intensity
and extension (hematoxylin-eosin; original magnification, 40⫻) (F) MTA, 30
days. Higher magnification of (E). Although there are irregularities in the hard
tissue bridge, a complete hard tissue bridge was formed (white arrow). Observe
a chronic inflammatory infiltrate around the exposure site (hematoxylin-eosin;
original magnification, 100⫻). (G) MTA, 60 days. In this case, complete hard
tissue bridge is shown (white arrow). Only chronic inflammatory infiltrate with
different intensity and extension can be seen near to dentin walls (black arrow)
(hematoxylin-eosin; original magnification, 40⫻). (H) MTA, 60 days. Higher mag-
nification of (G). Observe hard bridge tissue (white arrow), new odontoblast layer
in contact with hard bridge (black arrow), and normal pulpal tissue near hard
bridge tissue (black *) (hematoxylin-eosin; original magnification, 100⫻).
The results of this study should be carefully evaluated because the
capping procedure was accomplished in sound teeth. In most clinical
scenarios, the pulp exposure frequently occurs by a carious process in
which the level of inflammation is much higher. The ideal would be
JOE — Volume 34, Number 1, January 2008
Clinical Research
testing these procedures under the aforementioned condition to verify
the reproducibility of the findings reported in this clinical evaluation.
However, although the use of vital healthy teeth for this kind of study has
limitations, it still has the benefit of standardization and can be regarded
as acceptable in respect to material selection and handling.
The histomorphologic features of this study support the fact that
MTA can be safely used for pulpal capping of human teeth. MTA seemed
to heal the pulp tissue at a faster rate than Ca(OH)2 cement, although
after 60 days both materials reached similar and excellent results for
pulp capping in human teeth.
Acknowledgments
This study was partially supported by CNPq Grants (551049/
2002-2, 350085/2003-0, 302552/2003-0, and 474225-2003-8).
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JOE — Volume 34, Number 1, January 2008