Practice-based trial find better outcomes with MTA for direct pulp-capping in permanent teeth


Exposure of the dental pulp is an occasional hazard associated with dental treatment. Direct pulp capping is a procedure in which a medicament is placed directly over the exposed dental pulp, with the specific aim of maintaining pulp vitality and health. Calcium hydroxide (CaOH) has for many years been considered the material of choice for this procedure recently the new cement (mineral trioxide aggregate, MTA) has become a popular alternative.  The aim of this practice –based trial was to compare the success of direct pulp capping in permanent teeth with MTA vs.CaOH.

Practices were randomised to use CaOH  or MTA  and if the dentist- investigator deemed that a direct pulp cap was the appropriate clinical procedure, they then performed the pulp cap
  using the assigned capping agent (MTA or CaOH).  The tooth could not have any radicular radiolucency or history of spontaneous or lingering pain in response to temperature or biting. Only one pulp cap per patient was eligible. A radiograph was taken after the pulp-capping procedure if one within the preceding 6 months was not available. Teeth were followed for up 
to 2 years or until the tooth required extraction or root canal therapy. Radiographs were taken at 2 years.  Recommendation for tooth extraction, root canal treatment or radiolucency on radiograph was considered a failure.

  • 43 practices were enrolled with 35 practices enrolling 376 patients.
  • The median follow up in the CaOH group was 12.1 months (range, 0.2 to 30.9 )
  • The median follow up in the MTA group was 15.6 months (range, 0.2 to 33.5 )
  • Numbers recommended for extraction or root capping were;  45 in the CaOH group   and 25 in the MTA group 25
  • The Kaplan-Meier estimate for pulp cap failure by 24 months for CaOH treatment was 31.5% vs. 19.7% for teeth pulp-capped with MTA
  • An additional 3 radiographic failures were identified in the MTA group
    • This gives an overall failure rate of 31.5% for CaOH
 and 22.4% for MTA (p = .067)
  • One practice had a significant number of failures (56%). Following exclusion of that practice the failure rate can be recalculated as 27.1%  for CaOH and 19.7% for MTA (p =0.90)

The authors concluded

This large randomized clinical trial, conducted for up to 2 years within a practice-based research network, provided confirmatory evidence for a superior performance with MTA as a direct pulp-capping agent as compared with CaOH


The 2007 Cochrane review ( Miyashita et al)  found little or no evidence as to the most effective pulp-capping material so this large trail is welcome.


Comparison of CaOH with MTA for Direct Pulp Capping : A PBRN Randomized Clinical Trial. T.J. Hilton, J.L. Ferracane, L. Mancl and for Northwest Practice-based Research Collaborative in Evidence-based Dentistry (NWP) J DENT RES published online 20 May 2013
DOI: 10.1177/0022034513484336

Miyashita H, Worthington HV, Qualtrough A, Plasschaert A. Pulp management for caries in adults: maintaining pulp vitality. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004484. DOI: 10.1002/14651858.CD004484.pub2.



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Derek Richards

Derek Richards is a specialist in dental public health, Director of the Centre for Evidence-Based Dentistry and Specialist Advisor to the Scottish Dental Clinical Effectiveness Programme (SDCEP) Development Team. A former editor of the Evidence-Based Dentistry Journal and chief blogger for the Dental Elf website until December 2023. Derek has been involved with a wide range of evidence-based initiatives both nationally and internationally since 1994. Derek retired from the NHS in 2019 remaining as a part-time senior lecturer at Dundee Dental School until the end of 2023.

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