ABSTRACT

Objective:

To verify, through clinical and radiographic evaluations, the in vivo response of the dentin-pulpal complex of human primary teeth after pulpotomy with MTA and Biodentine™ in a follow-up period of 3, 6, and 12 months.

Material and Methods:

Thirty teeth were divided into MTA pulpotomy (n = 15) and Biodentine™ pulpotomy (n = 15) from children between 5 and 9 years of age, a randomized clinical trial with simple random sampling. The materials were inserted into the cavity after opening and removing the coronary pulp tissue. The cavity base consisted of glass ionomer cement and light-cured composite resin restoration. Clinical and radiographic analyses were performed after 3, 6, and 12 months. Statistical analysis by Fisher's exact test for dichotomous data at a 5% significance level was utilized.

Results:

Both materials caused color change after 12 months. However, MTA showed a higher percentage than Biodentine™ (p<0.0001). Pain was detected only with Biodentine™ at six months and mobility at 12 months (p=0.0013). Radiographically, after 12 months, periapical lesions, interradicular lesions, and internal resorption were evidenced in 13% of the cases for Biodentine™-treated teeth (p<0.0013). MTA induced pulp calcification in 13% of cases, unlike Biodentine™ (p<0.0013).

Conclusion:

Biodentine^TM and MTA are suitable for clinical use in pulpotomy treatment, yet both materials lead to tooth discoloration.

Keywords:
Pulpotomy; Tooth, Deciduous; Pediatric Dentistry; Dental Pulp Cavity

Introduction

Pulpotomy is a therapy often performed on primary teeth and is defined as removing pulp tissue located in the coronal portion of the tooth, which may be inflamed or infected [¹1 Bossù M, Iaculli F, Di Giorgio G, Salucci A, Polimeni A, Di Carlo S. Different pulp dressing materials for the pulpotomy of primary teeth: a systematic review of the literature. J Clin Med 2020; 9(3):838. https://doi.org/10.3390/jcm9030838
https://doi.org/10.3390/jcm9030838... ]. After removing this coronary pulp tissue, materials that preserve vitality and promote the repair of the remaining root pulp tissue, evidenced by the neoformation of mineralized tissue [²2 De Rossi A, Silva LA, Gatón-Hernández P, Sousa-Neto MD, Nelson-Filho P, Silva RA, et al. Comparison of pulpal responses to pulpotomy and pulp capping with biodentine and mineral trioxide aggregate in dogs. J Endod 2014; 40(9):1362-9. https://doi.org/10.1016/j.joen.2014.02.006
https://doi.org/10.1016/j.joen.2014.02.0... -³3 Daltoé MO, Paula-Silva FW, Faccioli LH, Gatón-Hernández PM, De Rossi A, Bezerra Silva LA. Expression of mineralization markers during pulp response to biodentine and mineral trioxide aggregate. J Endod 2016; 42(4):596-603. https://doi.org/10.1016/j.joen.2015.12.018
https://doi.org/10.1016/j.joen.2015.12.0... ], can be applied. Regarding the materials used, the most common are mineral trioxide aggregate (MTA), Biodentine™ (BD), and calcium hydroxide (CH) [¹1 Bossù M, Iaculli F, Di Giorgio G, Salucci A, Polimeni A, Di Carlo S. Different pulp dressing materials for the pulpotomy of primary teeth: a systematic review of the literature. J Clin Med 2020; 9(3):838. https://doi.org/10.3390/jcm9030838
https://doi.org/10.3390/jcm9030838... ].

MTA has calcium, aluminum, and selenium in its composition, present excellent properties such as biocompatibility, bioactivity, hydrophilicity, radiopacity, sealing ability, and low solubility [⁴4 Tawil PZ, Duggan DJ, Galicia JC. Mineral trioxide aggregate (MTA): its history, composition, and clinical applications. Compend Contin Educ Dent 2015; 36(4):247-52; quiz 254, 264.]. It is indicated for pulp capping, pulpotomy, apexogenesis, apexification, regeneration of the pulp-dentin complex, root perforation, and endodontic treatment [⁴4 Tawil PZ, Duggan DJ, Galicia JC. Mineral trioxide aggregate (MTA): its history, composition, and clinical applications. Compend Contin Educ Dent 2015; 36(4):247-52; quiz 254, 264.]. However, MTA has some disadvantages, such as tooth staining, long hardening time (more than 2 hours) [⁵5 Stringhini Junior E, Dos Santos MGC, Oliveira LB, Mercadé M. MTA and biodentine for primary teeth pulpotomy: a systematic review and meta-analysis of clinical trials. Clin Oral Investig 2019; 23(4):1967-76. https://doi.org/10.1007/s00784-018-2616-6
https://doi.org/10.1007/s00784-018-2616-... ], need for hydration during this period [⁶6 Pérard M, Le Clerc J, Watrin T, Meary F, Pérez F, Tricot-Doleux S, et al. Spheroid model study comparing the biocompatibility of Biodentine and MTA. J Mater Sci Mater Med 2013; 24(6):1527-34. https://doi.org/10.1007/s10856-013-4908-3 Erratum in: J Mater Sci Mater Med 2013; 24(9):2275.
https://doi.org/10.1007/s10856-013-4908-... ], difficulties in handling, and high cost [⁵5 Stringhini Junior E, Dos Santos MGC, Oliveira LB, Mercadé M. MTA and biodentine for primary teeth pulpotomy: a systematic review and meta-analysis of clinical trials. Clin Oral Investig 2019; 23(4):1967-76. https://doi.org/10.1007/s00784-018-2616-6
https://doi.org/10.1007/s00784-018-2616-... ,⁷7 Walker LA, Sanders BJ, Jones JE, Williamson CA, Dean JA, Legan JJ, et al. Current trends in pulp therapy: a survey analyzing pulpotomy techniques taught in pediatric dental residency programs. J Dent Child 2013; 80(1):31-5.]. Since the main active component of MTA is tricalcium silicate, researchers have sought to develop materials that present this component in its pure form, synthesized in the laboratory under controlled conditions from raw materials of unknown nature. Attempts to replace Portland cement resulted in the experimental development of dental materials containing pure tricalcium silicate with adequate physical properties [⁸8 Camilleri J, Montesin FE, Juszczyk AS, Papaioannou S, Curtis RV, Donald FM, et al. The constitution, physical properties and biocompatibility of modified accelerated cement. Dent Mater 2008; 24(3):341-50. https://doi.org/10.1016/j.dental.2007.06.004
https://doi.org/10.1016/j.dental.2007.06... ,⁹9 Sorrentino F. Upscaling the synthesis of tricalcium silicate and alite. Cement Wapno Beto 2008; 8:177–83.], antimicrobial action comparable to calcium hydroxide, and good sealing capacity [¹⁰10 Wang X, Chang J, Hu S. A study on the sealing ability and antibacterial activity of Ca3SiO5/CaCl2 composite cement for dental applications. Dent Mater J 2012; 31(4):617-22. https://doi.org/10.4012/dmj.2011-260
https://doi.org/10.4012/dmj.2011-260... ].

BD is a tricalcium silicate-based cement launched in Europe and has received favorable reviews in the literature due to its better handling and biocompatibility characteristics [¹¹11 Martens LC, Rajasekharan S, Jacquet W, Vandenbulcke JD, Van Acker JWG, Cauwels RGEC. Paediatric dental emergencies: a retrospective study and a proposal for definition and guidelines including pain management. Eur Arch Paediatr Dent 2018; 19(4):245-53. https://doi.org/10.1007/s40368-018-0353-9
https://doi.org/10.1007/s40368-018-0353-... ]. According to the manufacturer, BD is a biological material with good physical and chemical properties and high mechanical strength, acting as a substitute for dentin in restorative procedures without the need for surface acid etching. BD is presented in capsules containing the powder, which consists of tricalcium silicate, dicalcium silicate, calcium oxide and carbonate, and zirconium oxide (radiopacifier), and the liquid consisting of calcium chloride, the agent responsible for reducing the hardening time and a water-soluble polymer which maintains good flowability with a low water/solid ratio [¹²12 Septodont. Biodentine Scientific File. Active Biosilicate Technology. Saint-Maur-des-fossés, France: R&D Department, Septodont; 2010. Available from: http://www.septodont.fr [Accessed on 10 November, 2013]. [In French].
http://www.septodont.fr... ].

The main advantages of using BD over MTA include ease of handling, high viscosity, shorter hardening time (12 minutes), and better physical properties [¹³13 Villat C, Tran XV, Pradelle-Plasse N, Ponthiaux P, Wenger F, Grosgogeat B, et al. Impedance methodology: A new way to characterize the setting reaction of dental cements. Dent Mater 2010; 26(12): 1127-32. https://doi.org/10.1016/j.dental.2010.07.013 Erratum in: Dent Mater 2011; 27(5):507.
https://doi.org/10.1016/j.dental.2010.07... ,¹⁴14 Nowicka A, Lipski M, Parafiniuk M, Sporniak-Tutak K, Lichota D, Kosierkiewicz A, et al. Response of human dental pulp capped with biodentine and mineral trioxide aggregate. J Endod 2013; 39(6):743-7. https://doi.org/10.1016/j.joen.2013.01.005
https://doi.org/10.1016/j.joen.2013.01.0... ], in addition to having material of known purity in its composition [¹⁵15 Pradelle-Plasse N, Tran Xuan-Vin C. Physico-chemical properties of Biodentine. In: Goldberg M. Biocompatibility or Cytotoxic Effects of Dental Composites. 1st. ed. Oxford: Coxmoor Publishing; 2009.]. Despite presenting differences with respect to MTA in composition and setting time, BD allows the deposition of hydroxyapatite on its surface when exposed to body fluid [¹⁶16 Camilleri J, Sorrentino F, Damidot D. Investigation of the hydration and bioactivity of radiopacified tricalcium silicate cement, Biodentine and MTA Angelus. Dent Mater 2013; 29(5):580-93. https://doi.org/10.1016/j.dental.2013.03.007
https://doi.org/10.1016/j.dental.2013.03... ], has color stability [¹⁷17 Vallés M, Mercadé M, Duran-Sindreu F, Bourdelande JL, Roig M. Influence of light and oxygen on the color stability of five calcium silicate-based materials. J Endod 2013; 39(4):525-8. https://doi.org/10.1016/jjoen.2012.12.021
https://doi.org/10.1016/jjoen.2012.12.02... ], is non-genotoxic [¹⁸18 Opačić-Galić V, Petrović V, Zivković S, Jokanović V, Nikolić B, Knežević-Vukčević J, et al. New nanostructural biomaterials based on active silicate systems and hydroxyapatite: characterization and genotoxicity in human peripheral blood lymphocytes. Int Endod J 2013; 46(6):506-16. https://doi.org/10.1111/iej.12017
https://doi.org/10.1111/iej.12017... ], and has low cytotoxicity [¹⁹19 Laurent P, Camps J, De Méo M, Déjou J, About I. Induction of specific cell responses to a Ca(3)SiO(5)-based posterior restorative material. Dent Mater 2008; 24(11): 1486-94. https://doi.org/10.1016/j.dental.2008.02.020
https://doi.org/10.1016/j.dental.2008.02... ], maintaining the viability of gingival fibroblasts [²⁰20 Zhou HM, Shen Y, Wang ZJ, Li L, Zheng YF, Häkkinen L, et al. In vitro cytotoxicity evaluation of a novel root repair material. J Endod 2013; 39(4):478-83. https://doi.org/10.1016/j.joen.2012.11.026
https://doi.org/10.1016/j.joen.2012.11.0... ]. In vitro studies with BD have shown compatibility with dental pulp cells and stimulated tertiary dentin formation [⁶6 Pérard M, Le Clerc J, Watrin T, Meary F, Pérez F, Tricot-Doleux S, et al. Spheroid model study comparing the biocompatibility of Biodentine and MTA. J Mater Sci Mater Med 2013; 24(6):1527-34. https://doi.org/10.1007/s10856-013-4908-3 Erratum in: J Mater Sci Mater Med 2013; 24(9):2275.
https://doi.org/10.1007/s10856-013-4908-... ,¹⁹19 Laurent P, Camps J, De Méo M, Déjou J, About I. Induction of specific cell responses to a Ca(3)SiO(5)-based posterior restorative material. Dent Mater 2008; 24(11): 1486-94. https://doi.org/10.1016/j.dental.2008.02.020
https://doi.org/10.1016/j.dental.2008.02... ,²¹21 Zanini M, Sautier JM, Berdal A, Simon S. Biodentine induces immortalized murine pulp cell differentiation into odontoblast-like cells and stimulates biomineralization. J Endod 2012; 38(9): 1220-6. https://doi.org/10.1016/jjoen.2012.04.018
https://doi.org/10.1016/jjoen.2012.04.01... ,²²22 Laurent P, Camps J, About I. Biodentine(TM) induces TGF-ß 1 release from human pulp cells and early dental pulp mineralization. Int Endod J 2012; 45(5):439-48. https://doi.org/10.1111/j.1365-2591.2011.01995.x
https://doi.org/10.1111/j.1365-2591.2011... ,²³23 Chang SW, Lee SY, Ann HJ, Kum KY, Kim EC. Effects of calcium silicate endodontic cements on biocompatibility and mineralization-inducing potentials in human dental pulp cells. J Endod 2014; 40(8): 1194-200. https://doi.org/10.1016/j.joen.2014.01.001
https://doi.org/10.1016/j.joen.2014.01.0... ,²⁴24 Jung JY, Woo SM, Lee BN, Koh JT, Nör JE, Hwang YC. Effect of Biodentine and Bioaggregate on odontoblastic differentiation via mitogen-activated protein kinase pathway in human dental pulp cells. Int Endod J 2015; 48(2): 177-84. https://doi.org/10.1111/iej.12298
https://doi.org/10.1111/iej.12298... ,²⁵25 Lee BN, Lee KN, Koh JT, Min KS, Chang HS, Hwang IN, et al. Effects of 3 endodontic bioactive cements on osteogenic differentiation in mesenchymal stem cells. J Endod 2014; 40(8): 1217-22. https://doi.org/10.1016/j.joen.2014.01.036
https://doi.org/10.1016/j.joen.2014.01.0... ]. The application of BD to pulp cells allowed their differentiation into odontoblast-like cells [²¹21 Zanini M, Sautier JM, Berdal A, Simon S. Biodentine induces immortalized murine pulp cell differentiation into odontoblast-like cells and stimulates biomineralization. J Endod 2012; 38(9): 1220-6. https://doi.org/10.1016/jjoen.2012.04.018
https://doi.org/10.1016/jjoen.2012.04.01... ] and induced the formation of foci of mineralized tissue similar to MTA and calcium hydroxide [¹⁹19 Laurent P, Camps J, De Méo M, Déjou J, About I. Induction of specific cell responses to a Ca(3)SiO(5)-based posterior restorative material. Dent Mater 2008; 24(11): 1486-94. https://doi.org/10.1016/j.dental.2008.02.020
https://doi.org/10.1016/j.dental.2008.02... ,²⁶26 Luo Z, Kohli MR, Yu Q, Kim S, Qu T, He WX. Biodentine induces human dental pulp stem cell differentiation through mitogen-activated protein kinase and calcium-/calmodulin-dependent protein kinase II pathways. J Endod 2014; 40(7):937-42. https://doi.org/10.1016/j.joen.2013.11.022
https://doi.org/10.1016/j.joen.2013.11.0... ]. Systematic reviews and meta-analyses comparing MTA and BD have not demonstrated differences in clinical and radiographic success between these materials [¹1 Bossù M, Iaculli F, Di Giorgio G, Salucci A, Polimeni A, Di Carlo S. Different pulp dressing materials for the pulpotomy of primary teeth: a systematic review of the literature. J Clin Med 2020; 9(3):838. https://doi.org/10.3390/jcm9030838
https://doi.org/10.3390/jcm9030838... ,⁵5 Stringhini Junior E, Dos Santos MGC, Oliveira LB, Mercadé M. MTA and biodentine for primary teeth pulpotomy: a systematic review and meta-analysis of clinical trials. Clin Oral Investig 2019; 23(4):1967-76. https://doi.org/10.1007/s00784-018-2616-6
https://doi.org/10.1007/s00784-018-2616-... ]. Since BD was developed as a dentin replacement material, it becomes timely to investigate the use of this material for the conservative treatment of pulp tissue in primary teeth. The null hypothesis is that the response of the dentin-pulpal complex is similar in teeth treated with pulpotomy with MTA or BD material in primary teeth. Therefore, the objective of the present study was to verify, through clinical and radiographic evaluations, the in vivo response of the dentin-pulpal complex of human primary teeth after pulpotomy with MTA and BD in a follow-up period of 3, 6, and 12 months.

Material and Methods

Ethical Clearance

The present work was approved by the Human Research Ethics Committee of the Ribeirão Preto School of Dentistry (FORP) – University of São Paulo (process: 35908214.3.0000.5419).

Sample Selection

In the present study, pulpotomies were performed on the primary teeth of children aged 5 to 9. All the legal guardians of the selected children read and signed a Free and Informed Consent Form. Clinical and radiographic procedures were performed by a previously calibrated operator at the Pediatric Dentistry Clinic of FORP-USP.

A randomized clinical trial was carried out with simple random sampling to divide the groups, and the draw was done by tossing a coin. The selection of the sample was performed by clinical and radiographic analyses of the teeth according to the following inclusion criteria: (i) maxillary and mandibular first or second deciduous molars compromised by deep caries; (ii) absence of fistula or abscess; (iii) radiographic absence of internal and external resorption of more than 2/3 of the root; (iv) absence of lesions in the furcation region and the periapex; (v) possibility of tooth restoration. Individuals with systemic pathologies were excluded. The teeth were randomly divided into groups: Group 1 – Pulpotomy with MTA (n= 15) and Group 2 – Pulpotomy with BD (n= 15).

Clinical Procedures

All instruments used in the surgical procedures, including the gauze pads and cotton balls, were sterilized in an autoclave. The clinical technique steps included topical anesthesia and infiltrative anesthesia (upper teeth) or by blockade (lower teeth) (1 to 4% Mepivacaine with Epinephrine 1:100,000, DFL Indústria e Comércio S.A); after complete isolation with a rubber dam and clamps that fit the tooth correctly. Asepsis was performed with 2% chlorhexidine, and the carious lesion was removed with dentine curettes (#2, 3, 4 – S.S. White Artigos Dentários Ltda). The coronal opening, as well as the removal of the pulp chamber roof, were performed with spherical diamond burs (1014, 1015 - KG Sorensen), in high rotation under irrigation, and the removal of the coronal pulp was performed manually with dentine curettes.

After removing the pulp chamber roof and undergoing direct clinical examination, the pulp tissue, considered macroscopically vital, was submitted to pulpotomy and coated with different materials. In Group 1, the MTA powder was mixed with the distilled water accompanying the product in a 3:1 ratio. The cement handling was done to present a homogeneous mass of white color and a shiny surface at the end. The MTA was introduced into the tooth's pulp chamber with the aid of a padding foot and gently pressed against the tooth to adapt to the floor and cavity walls with at least 2 mm of thickness. In Group 2, the manipulation of BD was performed in an automated way in a mixing device (capsule amalgamator mixer), as recommended by the manufacturer. The capsule containing the powder was opened, and the liquid was introduced. Next, the capsule was closed and submitted to the mixing device for 30 seconds. The mixture was removed from the capsule and introduced into the pulp chamber with at least 2 mm of thickness with a padding foot and gently pressed against the tooth to adapt to the floor and cavity walls.

For both groups, a glass ionomer base (Vidrion R – S.S. White Artigos Dentários Ltda), approximately 2 mm thick, was made in the coronary chamber, and the definitive restoration was performed with Z250 lightcuring composite resin (3M/ESPE) and radiographed after immediate treatment (Figure 1).

Figure 1
Representative photographs of the pulpotomy procedure with BD on element 75. (a) Coronary opening and access to pulp, (b) Initial radiograph demonstrating the depth of caries, (c) Removal of the coronary pulp and evaluation of the macroscopic aspects of the tissue (cut-resistant pulp, bright red color), (d) Hemostasis after irrigation with 0.9% saline and sterile cotton balls, (e) Insertion of the BD into the cavity, with at least 2 mm of material thickness, (f) Final restoration with composite resin.

Clinical and Radiographic Analysis

The pulpotomized teeth were evaluated clinically and radiographically at 3, 6, and 12 months for pulp response analysis as previously described £27,28]. All precautions regarding the risks related to the radiographic imaging were carefully controlled through the use of an apron and thyroid protector coated with lead rubber, child positioners for performing the technique, and ultrafast radiographic film (Kodak Insight EF Sensitivity Films, size no. l), allowing a low exposure time to radiation. The focus/film distance of approximately 20 cm in a dental X-ray machine with 70kV and 10mA was maintained with an exposure time of 0.5 seconds. The development of radiographs was performed using automatic processing (A/T2000XR - Air Techniques).

Clinical success was considered when the teeth were presented with an absence of pain, mobility, and sensitivity to percussion, abscess/fistula, and color change. Radiographic success was considered when there was no internal root resorption, furcation, radiolucent interradicular area involvement, pulp calcification, periapical lesion, or formation of a dentinal barrier. The results obtained were analyzed using the GraphPad Prism 5.0 Software (Prism, Chicago, IL, USA), with statistical analysis using Fisher's exact test for dichotomous data at a significance level of 5%.

Results

Clinical Evaluation

Both BD and MTA led to tooth discoloration. Comparatively, the MTA led to tooth staining at six months (n= 6 - 40%), which was not observed in the BD (p<0.000l). At 12 months, a higher percentage of specimens in the MTA (n = 11 — 73%) group showed staining compared to the BD (n= 5 - 33%) (p<0.000l).

Painful symptoms were detected six months after using BD (n = 2 — 13%) (p=0.0013), however, it was not detected at 12 months. Teeth treated with MTA showed no painful symptoms.

Mobility was detected 12 months after using BD (n = 2 — 13%), but it was not detected in teeth treated with MTA (p=0.0013).

Fistula, foul odor, and increased sensitivity to percussion were not identified in any period, regardless of the material used (Table 1).

Radiographic Evaluation

Radiographically, in teeth treated with BD, periapical lesions, inter-radicular lesions, and internal resorption were observed in 13% of cases (n = 2), unlike teeth that received MTA as a material for pulp protection (p<0.0013). On the other hand, the MTA induced pulp calcification in 13% of cases (n = 2), unlike the BD (p < 0.0013). All these radiographic changes were observed 12 months after the pulpotomy (Figure 2).

Figure 2
Representative radiographs of pulpotomies in primary teeth with MTA (a-c) or BD (d-f). Diagnostic X-ray (a and d). Radiograph after pulpotomy with MTA (b) or BD (e). Follow-up radiograph after one year of pulpotomy treatment with MTA (d) or BD (f).

Furcation resorption and mineralized tissue barrier in direct contact with the protective material were not observed in any period, regardless of the material used (Table 2). Thus, the MTA's clinical and radiographic success rate was 100%, although it presented a color change. However, BD presented a rate of 87%.

Discussion

Pulpotomy is defined as removing the coronal pulp from a living pulp to preserve the remaining root pulp for conservative treatments or temporary pain relief [²⁹29 American Association of Endodontists. Glossary of Endodontic Terms. 10th ed. Chicago, IL: American Association of Endodontists; 2020.]. The application of biocompatible materials on the root pulp tissue can preserve vitality and stimulate the neoformation of mineralized tissue [²2 De Rossi A, Silva LA, Gatón-Hernández P, Sousa-Neto MD, Nelson-Filho P, Silva RA, et al. Comparison of pulpal responses to pulpotomy and pulp capping with biodentine and mineral trioxide aggregate in dogs. J Endod 2014; 40(9):1362-9. https://doi.org/10.1016/j.joen.2014.02.006
https://doi.org/10.1016/j.joen.2014.02.0... ,³3 Daltoé MO, Paula-Silva FW, Faccioli LH, Gatón-Hernández PM, De Rossi A, Bezerra Silva LA. Expression of mineralization markers during pulp response to biodentine and mineral trioxide aggregate. J Endod 2016; 42(4):596-603. https://doi.org/10.1016/j.joen.2015.12.018
https://doi.org/10.1016/j.joen.2015.12.0... ]. In the present study, we chose to compare MTA and BD since we can observe in the literature that they have similar clinical successes in approximately 100% of the cases [²⁷27 Sakai VT, Moretti AB, Oliveira TM, Fornetti AP, Santos CF, Machado MA, et al. Pulpotomy of human primary molars with MTA and Portland cement: a randomised controlled trial. Br Dent J 2009; 207(3):E5; discussion 128-9. https://doi.org/10.1038/sj.bdj.2009.665
https://doi.org/10.1038/sj.bdj.2009.665... ,³⁰30 Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial. Int Endod J 2008; 41(2): 128-50. https://doi.org/10.1111/j.1365-2591.2007.01329.x
https://doi.org/10.1111/j.1365-2591.2007... ,³¹31 Hugar SM, Deshpande SD. Comparative investigation of clinical/radiographical signs of mineral trioxide aggregate and formocresol on pulpotomized primary molars. Contemp Clin Dent 2010; 1(3): 146-51. https://doi.org/10.4103/0976-237X.72779
https://doi.org/10.4103/0976-237X.72779... ,³²32 Cardoso-Silva C, Barbería E, Maroto M, García-Godoy F. Clinical study of Mineral Trioxide Aggregate in primary molars. Comparison between Grey and White MTA--a long term follow-up (84 months). J Dent 2011; 39(2): 187-93. https://doi.org/10.1016/j.jdent.2010.11.010
https://doi.org/10.1016/j.jdent.2010.11.... ,³³33 Oliveira TM, Moretti AB, Sakai VT, Lourenço Neto N, Santos CF, Machado MA, et al. Clinical, radiographic and histologic analysis of the effects of pulp capping materials used in pulpotomies of human primary teeth. Eur Arch Paediatr Dent 2013; 14(2):65-71. https://doi.org/10.1007/s40368-013-0015-x
https://doi.org/10.1007/s40368-013-0015-... ,³⁴34 El Meligy OAES, Alamoudi NM, Allazzam SM, El-Housseiny AAM. Biodentine™ versus formocresol pulpotomy technique in primary molars: a 12-month randomized controlled clinical trial. BMC Oral Health 2019; 19(1):3. https://doi.org/10.1186/s12903-018-0702-4
https://doi.org/10.1186/s12903-018-0702-... ,³⁵35 Brar KA, Kratunova E, Avenetti D, da Fonseca MA, Marion I, Alapati S. Success of biodentine and ferric sulfate as pulpotomy materials in primary molars: a retrospective study. J Clin Pediatr Dent 2021; 45(1):22-8. https://doi.org/10.17796/1053-4625-45.1.5
https://doi.org/10.17796/1053-4625-45.1.... ]. Recent studies demonstrate the clinical and radiographic success of teeth that underwent pulpotomy with MTA or BD [³⁶36 Çelik BN, Mutluay MS, Arıkan V, Sarı Ş. The evaluation of MTA and Biodentine as a pulpotomy materials for carious exposures in primary teeth. Clin Oral Investig 2019; 23(2):661-6. https://doi.org/10.1007/s00784-018-2472-4
https://doi.org/10.1007/s00784-018-2472-... ,³⁷37 Abuelniel GM, Duggal MS, Kabel N. A comparison of MTA and Biodentine as medicaments for pulpotomy in traumatized anterior immature permanent teeth: A randomized clinical trial. Dent Traumatol 2020; 36(4):400-10. https://doi.org/10.1111/edt.12553
https://doi.org/10.1111/edt.12553... ].

After 12 months, the success was 87% for the BD, while the MTA presented 100% with no statistical difference. Similar results occurred in the studies of Çelik et al. [³⁶36 Çelik BN, Mutluay MS, Arıkan V, Sarı Ş. The evaluation of MTA and Biodentine as a pulpotomy materials for carious exposures in primary teeth. Clin Oral Investig 2019; 23(2):661-6. https://doi.org/10.1007/s00784-018-2472-4
https://doi.org/10.1007/s00784-018-2472-... ], who presented a success rate of 100% in the first six months, and from 12 months onwards, the BD presented 89.4% clinical and radiographic success, and in Cuadros-Fernández et al. [³⁸38 Cuadros-Fernández C, Lorente Rodríguez AI, Sáez-Martínez S, García-Binimelis J, About I, Mercadé M. Short-term treatment outcome of pulpotomies in primary molars using mineral trioxide aggregate and Biodentine: a randomized clinical trial. Clin Oral Investig 2016; 20(7):1639-45. https://doi.org/10.1007/s00784-015-1656-4
https://doi.org/10.1007/s00784-015-1656-... ] after 12 months of follow-up was 92% for the MTA and 97% for the BD. A randomized clinical trial followed the success rate over a more extended period of 24 months and found that the success rates of MTA and BD were 97.2% and 99.4%, respectively [³⁹39 Vilella-Pastor S, Sáez S, Veloso A, Guinot-Jimeno F, Mercadé M. Long-term evaluation of primary teeth molar pulpotomies with Biodentine and MTA: a CONSORT randomized clinical trial. Eur Arch Paediatr Dent 2021; 22(4):685-92. https://doi.org/10.1007/s40368-021-00616-3
https://doi.org/10.1007/s40368-021-00616... ]. After the 12-month follow-up, the success rate showed no difference in the BD and MTA materials 88.46% of the cases [⁴⁰40 Eshghi A, Hajiahmadi M, Nikbakht MH, Esmaeili M. Comparison of clinical and radiographic success between MTA and biodentine in pulpotomy of primary mandibular second molars with irreversible pulpitis: a randomized doubleblind clinical trial. Int J Dent 2022; 2022:6963944. https://doi.org/10.1155/2022/6963944
https://doi.org/10.1155/2022/6963944... ].

In their study, Abuelniel et al. [³⁷37 Abuelniel GM, Duggal MS, Kabel N. A comparison of MTA and Biodentine as medicaments for pulpotomy in traumatized anterior immature permanent teeth: A randomized clinical trial. Dent Traumatol 2020; 36(4):400-10. https://doi.org/10.1111/edt.12553
https://doi.org/10.1111/edt.12553... ] clinically demonstrated that after 12 months, 16% of the BD group and 12% of the MTA group presented pain, mobility, and edema. Another critical factor is that in the present results, the MTA group presented pulp calcification in 13% of the teeth treated in 12 months, unlike Çelik et al. [³⁶36 Çelik BN, Mutluay MS, Arıkan V, Sarı Ş. The evaluation of MTA and Biodentine as a pulpotomy materials for carious exposures in primary teeth. Clin Oral Investig 2019; 23(2):661-6. https://doi.org/10.1007/s00784-018-2472-4
https://doi.org/10.1007/s00784-018-2472-... ], where teeth showed pulpal obliteration in six months. Internal root resorption could be observed in 1 tooth in the MTA group, whereas in the BD, two molars had internal root resorption and periapical lesions [³⁸38 Cuadros-Fernández C, Lorente Rodríguez AI, Sáez-Martínez S, García-Binimelis J, About I, Mercadé M. Short-term treatment outcome of pulpotomies in primary molars using mineral trioxide aggregate and Biodentine: a randomized clinical trial. Clin Oral Investig 2016; 20(7):1639-45. https://doi.org/10.1007/s00784-015-1656-4
https://doi.org/10.1007/s00784-015-1656-... ]. A similar result was found in the present study, in which, after one year, two teeth had internal root resorption and periapical lesions in the BD group. However, two teeth had obliterated the root canal in the MTA group. In another study, 11.56% of the MTA and BD groups showed treatment failure after 12 months of follow-up, with the main response being internal root resorption [⁴⁰40 Eshghi A, Hajiahmadi M, Nikbakht MH, Esmaeili M. Comparison of clinical and radiographic success between MTA and biodentine in pulpotomy of primary mandibular second molars with irreversible pulpitis: a randomized doubleblind clinical trial. Int J Dent 2022; 2022:6963944. https://doi.org/10.1155/2022/6963944
https://doi.org/10.1155/2022/6963944... ].

A major disadvantage of MTA is its dental staining, which in the study presented a rate of 27% of the treated teeth in the period of six months, and no cases occurred with the BD in this period. After 12 months, tooth staining increased in the MTA group in 73% of the teeth and 33% in the BD group. The result below was found in the literature with Abuelniel et al. [³⁷37 Abuelniel GM, Duggal MS, Kabel N. A comparison of MTA and Biodentine as medicaments for pulpotomy in traumatized anterior immature permanent teeth: A randomized clinical trial. Dent Traumatol 2020; 36(4):400-10. https://doi.org/10.1111/edt.12553
https://doi.org/10.1111/edt.12553... ], where after six months, 60% of pulpotomies and after 12 months, 92% of pulpotomies performed with MTA presented staining. A systematic review and meta-analysis showed the periods analyzed after conservative treatment being 6, 12, and 18 months. They concluded that after examining the studies, there were no differences between the groups regarding clinical and radiographic success [⁵5 Stringhini Junior E, Dos Santos MGC, Oliveira LB, Mercadé M. MTA and biodentine for primary teeth pulpotomy: a systematic review and meta-analysis of clinical trials. Clin Oral Investig 2019; 23(4):1967-76. https://doi.org/10.1007/s00784-018-2616-6
https://doi.org/10.1007/s00784-018-2616-... ]. This corroborates the results of the present study in which the clinical and radiographic responses at 3, 6, and 12 months were evaluated.

Randomized clinical studies have their limitations in that each patient responds differently to the same treatment, in addition to the varied age groups and being able to influence the responses due to physiological resorption occurring at specific ages. Radiographically, the radiopacity demonstrated between the materials may differ, causing a qualified professional to distinguish which material was used even though it was a blind study. Studies comparing the BD with MTA mention that the materials have similar clinical and radiographic responses; however, the BD can be an alternative for conservative treatments due to its characteristics of shorter setting time, easier handling, and absence of tooth staining [⁵5 Stringhini Junior E, Dos Santos MGC, Oliveira LB, Mercadé M. MTA and biodentine for primary teeth pulpotomy: a systematic review and meta-analysis of clinical trials. Clin Oral Investig 2019; 23(4):1967-76. https://doi.org/10.1007/s00784-018-2616-6
https://doi.org/10.1007/s00784-018-2616-... ,³⁶36 Çelik BN, Mutluay MS, Arıkan V, Sarı Ş. The evaluation of MTA and Biodentine as a pulpotomy materials for carious exposures in primary teeth. Clin Oral Investig 2019; 23(2):661-6. https://doi.org/10.1007/s00784-018-2472-4
https://doi.org/10.1007/s00784-018-2472-... ,³⁷37 Abuelniel GM, Duggal MS, Kabel N. A comparison of MTA and Biodentine as medicaments for pulpotomy in traumatized anterior immature permanent teeth: A randomized clinical trial. Dent Traumatol 2020; 36(4):400-10. https://doi.org/10.1111/edt.12553
https://doi.org/10.1111/edt.12553... ,³⁸38 Cuadros-Fernández C, Lorente Rodríguez AI, Sáez-Martínez S, García-Binimelis J, About I, Mercadé M. Short-term treatment outcome of pulpotomies in primary molars using mineral trioxide aggregate and Biodentine: a randomized clinical trial. Clin Oral Investig 2016; 20(7):1639-45. https://doi.org/10.1007/s00784-015-1656-4
https://doi.org/10.1007/s00784-015-1656-... ,³⁹39 Vilella-Pastor S, Sáez S, Veloso A, Guinot-Jimeno F, Mercadé M. Long-term evaluation of primary teeth molar pulpotomies with Biodentine and MTA: a CONSORT randomized clinical trial. Eur Arch Paediatr Dent 2021; 22(4):685-92. https://doi.org/10.1007/s40368-021-00616-3
https://doi.org/10.1007/s40368-021-00616... ,⁴⁰40 Eshghi A, Hajiahmadi M, Nikbakht MH, Esmaeili M. Comparison of clinical and radiographic success between MTA and biodentine in pulpotomy of primary mandibular second molars with irreversible pulpitis: a randomized doubleblind clinical trial. Int J Dent 2022; 2022:6963944. https://doi.org/10.1155/2022/6963944
https://doi.org/10.1155/2022/6963944... ].

Conclusion

Overall, the results obtained for both the BD and MTA, based on clinical and radiographic manifestations after treatment, indicate that the materials are suitable for clinical use. There is a caveat regarding the staining of the teeth since both induced color change.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

References

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