Hard Tissue Barrier Formation Research Articles

Effect of lateral extent of pulp tissue removal on the outcome of partial pulpotomy for managing cariously exposed mature permanent molars with symptomatic irreversible pulpitis: A randomized clinical trial.

The aim of this study is to compare the outcomes of restricted partial pulpotomy (R-PP) versus extended partial pulpotomy (E-PP) for managing cariously exposed mature permanent molars with symptomatic irreversible pulpitis (SIP). This double-arm, parallel designed randomized clinical trial was registered at clinicaltrials.gov (registration number: NCT05406557). Following random allocation, 43 participants of each group received the designated intervention. In the R-PP group, 2-3 mm of superficial pulp tissue was removed only from the exposure site, while chamber was completely de-roofed and 2-3 mm of superficial pulp tissue from entire chamber was removed in the E-PP group. Haemostasis was achieved using 3% sodium hypochlorite-soaked cotton pellets. Upon haemostasis, ProRoot mineral trioxide aggregate (ProRoot MTA) was placed over the pulpal wound, overlaid with a resin-modified glass ionomer liner, and restored with composite resin in the same visit. Outcome measures included clinical and radiographic success evaluation at 6 and 12 months, and pain assessment using the visual analogue scale pre-operatively and daily for 7 post-operative days. Nonparametric tests were used for variables including patient's age, pain intensities, mean analgesic consumption, and haemostasis time. Categorical variables including gender, caries type, analgesic intake, hard tissue barrier formation, clinical and radiographic success, and pulp sensibility responses were assessed using Chi-square or Fisher's exact test. Tooth survival was analysed using Kaplan-Meier analysis. A total of 81 cases were analysed at 12 months follow-up. Comparable success was observed in both groups (97.6% in E-PP & 97.5% in R-PP; p > .05). The R-PP group reported significantly lower pain scores on the 1st and 2nd post-operative days than E-PP (p < .05) and required significantly less analgesic intake (p < .05). Hard tissue barrier formation was significantly lower in the R-PP group (p < .05). No significant differences were observed between groups regarding haemostasis time, pulp sensibility responses, and tooth survival (p > .05). Both the PP approaches exhibited comparable success for managing cariously exposed mature permanent molars with SIP. Given the conservative nature of R-PP, it may be used as preferred PP approach for managing such cases. Being the first study of this kind, further work is necessary to draw definitive conclusions.

Efficacy of Chitosan Scaffolded Calcium Silicate-based Cements for Treating Internal Resorption Defects with Perforation: In Vitro Study.

The present study aimed to evaluate the efficacy of chitosan scaffold combined with calcium silicate cements in the management of internal resorption with perforation. Internal resorption cavities were simulated in 20 human permanent maxillary incisors that were then divided into two groups: group I - biodentine and group II - chitosan scaffold combined with biodentine. The samples were evaluated for the mineralization activity at the end of the 7th day and 14th day using scanning electron microscopy-energy dispersive X-ray (SEM-EDX) analysis. The data were recorded, tabulated, and then statistically analyzed. From the SEM-EDX analysis, the mean score of calcium and phosphorus ion uptake by the material was obtained. Statistical analysis by nonparametric Mann-Whitney test showed that there was statistically significant difference in calcium ion uptake at the end of the 7th day (p = 0.016) and at the end of 14th day (p = 0.043) between the group biodentine and group chitosan scaffold combined with biodentine (p < 0.05). In this present study, the use of chitosan scaffolds combined with biodentine showed a statistically significant difference in the mineralization activity when compared with pure biodentine. These scaffolded biomaterials exhibited greater potential for mineralization in vitro which can be efficiently used for the management of teeth with internal resorption with perforation. Further clinical trials are required for the understanding of their behavior in real-world scenarios. Calcium silicate cements have often exhibited defective hard tissue barrier formation and hence there is a pressing need to search for newer biomaterials that can overcome these shortcomings. Scaffolded biomaterials provide a controlled microcellular environment for bioactivity, and they were found to be efficient in the remineralization of tooth structure. The present study findings indicate that these chitosan scaffolds can be efficiently used in combination with calcium silicate cements for the management of internal resorption with perforation to enhance the treatment outcome.

Apexification of an infected untreated immature tooth with calplus (Calcium hydroxide paste with Iodoform)

Apexification is a method to induce a calcific barrier across an open apex or the sustained apical development of an incomplete root in teeth with necrotic pulp. Apical closure occurs approximately three years after eruption. Apexification is a treatment option that is done with the aim of apical repair by formation of hard tissue barrier through apex. Conventionally, a calcified barrier is inducted using a calcium hydroxide mixture. Various materials that can be used for apexification include Calcium hydroxide, MTA, Tricalcium phosphate, Dentin chips, Calcium phosphate ceramics and hydroxyapatite and bone morphogenetic proteins. Calcium hydroxide is the most common and traditional material employed for inducing apexification. Multi visit technique requiring 6-24 months to complete by using calcium hydroxide paste with Iodoform.

Three-dimensional qualitative and quantitative analyses of the effect of periradicular lesions on the outcome of regenerative endodontic procedures: A prospective clinical study

Qualitative and quantitative evaluation of the outcomes of regenerative endodontic procedure (REP) on human immature necrotic teeth with apical periodontitis using cone-beam computed tomography (CBCT) MATERIALS AND METHODS: Immature permanent teeth (n = 50) with necrotic pulp and periradicular pathosis were treated with a cell-homing concept-based REP. Following the procedure, a limited field-of-view CBCT scan was obtained. At each recall session (6, 12, 18 months), clinical tests were performed, and a digital periapical radiograph was taken. When significant radiographic changes were evident in the follow-up, a final CBCT scan was taken for qualitative and quantitative assessment. These initial and follow-up CBCT scans were assessed for quantification of changes in root length, pulp space diameter and periradicular lesion size. The data were statistically analysed using t test, one-way ANOVA, post hoc test and paired t test (P = 0.05). Of the teeth, 94.6% were clinically successful based on the lack or regression of signs and symptoms after 48 months follow-up. REP resulted in a statistically significant increase in root length, decrease in pulp space diameter and periradicular radiolucency (P < 0.05). CBCT images illustrated various patterns of root maturation including an increased thickening of the canal walls and continued root maturation (37.1%), continued root development with the apical foramen remaining open (57.1%), severe calcification (obliteration) of the canal space (2.9%) and hard tissue barrier formation in the canal space between the coronal plug and the root apex (2.9%). This study highlighted that the expected outcome of radiographic root development was less predictable when immature permanent teeth with periradicular pathosis were treated with REP. The size and extent (expansion/destruction of the cortical plate) of periradicular lesions and abscesses influence the outcome of REP. These factors must be taken into consideration during treatment planning.

Single-Visit Apexification of Immature Necrotic Permanent Teeth with the use of Mineral Trioxide Aggregate: A Case Series

The treatment of immature necrotic permanent teeth with wide open apices often poses a significant challenge for the clinician. The lack of an apical stop complicates the obturation and achievement of good apical seal in such teeth. The treatment of choice for necrotic teeth with immature root is apexification, which is induction of apical closure to produce more favorable conditions for conventional root canal filling. The most commonly advocated medicament is calcium hydroxide. But the disadvantages of long treatment time, tooth fracture risk and incomplete calcification of apical bridge have led to the development of newer biocompatible materials which can complete apexification in a single visit. Although different materials are available, Mineral Trioxide Aggregate (MTA) remains the material of choice for forming an immediate apical barrier because of its superior clinical properties and high success rate. This case series highlights the use of MTA for formation of hard tissue barrier in nonvital permanent teeth with open apices with demonstrated clinical and radiographic success.

Regenerative Endodontics: A Paradigm Shift in Clinical Endodontics.

ABSTRACTPreserving the natural dentition in its normal form and function is one of the major goals of endodontic treatment. Re-establishing the lost vitality and development of root maturation in immature permanent teeth with pulp necrosis/apical periodontitis is quiet challenging clinically. The very basis of regenerative endodontics relies on the concept of tissue engineering using stem cells, biomimetic scaffold, and bioactive growth factors to regenerate the pulp tissue damaged by microbial infection, injury, or developmental defects. In clinical endodontics, this approach is referred to as a “paradigm shift.” Even though repair instead of true regeneration is achieved with current protocols, it is hoped that further research in the area of stem-cell-based tissue engineering will allow for true regeneration and improved treatment outcomes. The aim of this review is to discuss about the various aspects of regenerative endodontics, current clinical protocols, and the future of pulp regeneration techniques.

Bone tissue response to an MTA-based endodontic sealer, and the effect of the addition of calcium aluminate and silver particles.

To evaluate bone tissue reactions in rats to an MTA-based endodontic sealer with and without the addition of various concentrations of C3A or C3A+Ag. Bone tissue reactions were evaluated in 45 Wistar rats after 7, 30 and 90days (n=5 per period). Three surgical cavities were prepared on the right femur and filled with 0.2 mL MTA Fillapex, MTA Fillapex+C3A and C3A+Ag at various concentrations: AH Plus (Dentsply DeTrey GmbH, Konstanz, Germany), EndoSequence BC (Brasseler USA, Savannah, GA, USA) or no sealer (negative control). By the end of each experimental period, animals were randomly euthanized. The samples were histologically processed and analysed using a light microscope. The presence of inflammatory cells, fibres and hard tissue barrier formation was evaluated. Data were analysed statistically using nonparametric tests to compare the differences between groups. Multiple groups were compared using the Kruskal-Wallis and Mann-Whitney U-tests with a Bonferroni correction at P=0.05. The inflammatory response significantly decreased from 30 to 90days (P<0.05). Fibre condensation was similar amongst the groups at 07 and 30days after intervention (P>0.05). At 90days, however, fibres were absent in most specimens of EndoSequence BC Sealer, AH Plus, MTA Fillapex and the control group, whilst they were still observed in samples of the modified sealers (P<0.05). At 90 days, all specimens of AH Plus, EndoSequence BC Sealer and control group had complete formation of hard tissue barrier. In the MTA Fillapex group, as well as in the modified sealers groups, partial deposition of mineralized tissue was noticed. The hypothesis tested that the incorporation of C3A and C3A+Ag particles to MTA Fillapex would improve bone tissue repair was partially accepted, since modified MTA Fillapex did not have the same repair potential as the commercial bioceramic material.

Outcomes of necrotic immature open-apex central incisors treated by MTA apexification using poly(ε-caprolactone) fiber mesh as an apical barrier.

Although unset mineral trioxide aggregate (MTA) has some cytotoxicity, MTA is still a biocompatible material suitable for doing apexification. This study assessed the outcomes for 8 necrotic immature open-apex permanent maxillary central incisors treated by MTA apexification using poly(ε-caprolactone) fiber mesh (PCL-FM) as an apical barrier (so-called PCL-FM/MTA apexification) to prevent extrusion of MTA materials into the periapical tissues of open-apex teeth. Eight necrotic immature open-apex permanent maxillary central incisors with the open apices measuring 2.5mm-3.5mm in diameter in 8 patients (6 boys and 2 girls; age range, 8-10 years) were first cleaned using ultrasonic activated irrigation with 2.5% sodium hypochlorite solution and then treated by PCL-FM/MTA apexification procedure. All the 8 permanent maxillary central incisors showed successful outcomes after PCL-FM/MTA apexification procedure. The mean duration for apical hard tissue barrier formation of the 8 incisors was 6.8±0.5 weeks (range 6-7 weeks). The mean increased root length was 1.8±0.7mm (range 1-3mm) at 7 weeks and 3.1±0.6mm (range 2-4mm) at 3 months. The mean increased dentinal wall thickness at the most apical portion of the root was 1.3±0.5mm (range 1-2mm) at 7 weeks and 2.4±0.6mm (range 1.5-3mm) at 3 months. None of the teeth treated by PCL-FM/MTA apexification showed tooth discoloration after a follow-up period of 3 months. PCL-FM/MTA apexification is an excellent technique for treatment of necrotic immature open-apex permanent maxillary central incisors.

Clinical, Radiological, and Histological Assessment of Magnetic Nanoparticles as Pulpotomy Medicament in Primary Molars.

Aim and objectivesAim of the study was to evaluate the success of magnetic nanoparticles (MNPs) as pulpotomy medicament by clinical, radiologic, and histological assessment in primary molars.Materials and methodsThe sample included 30 primary molars from 25 children aged between 3 and 9 years requiring pulpotomy treatment. Pulpotomy was carried out with MNPs. The teeth were evaluated after a period of 3, 6, and 12 months clinically and with the aid of radiographs. After 1 year, 10 teeth were extracted for histological evaluation under field emission scanning electron microscope (FE-SEM; ZEISS, Model No. Supra 55vp).ResultsOf the samples, 98% showed clinical success rate with absence of pain, swelling, mobility, and abscess formation. After 3 months, 98% radiological success with absence of periodontal ligament widening, root resorption, and inter-radicular radiolucency was noted. Histological examination carried out under FE-SEM revealed a zone of odontoblastic proliferation at the interface between MNPs and odontoblastic layer of pulp and viable pulpal cells from the canal orifice till apical foramen.ConclusionMagnetic nanoparticles can be recommended as an effective pulpotomy medicament with hard tissue barrier formation and preservation of vitality of remaining radicular pulp.How to cite this article: Konyala HR, Mareddy AR, Puppala N, Reddy NV, Mallela MK, Susheela KP. Clinical, Radiological, and Histological Assessment of Magnetic Nanoparticles as Pulpotomy Medicament in Primary Molars. Int J Clin Pediatr Dent 2018;11(4):283-287.

FR-Caによる歯根未完成歯アペキシフィケーション後の根尖閉鎖形態に関する臨床的, 走査電顕的観察

FR-Caによる歯根未完成歯アペキシフィケーション後の根尖閉鎖形態に関する臨床的, 走査電顕的観察

Pulp tissue response to Portland cement associated with different radio pacifying agents on pulpotomy of human primary molars.

The objective of this research was to evaluate the response of Portland cement associated with different radio pacifying agents on pulp treatment of human primary teeth by clinical and radiographic exams and microscopic analysis. Thirty mandibular primary molars were randomly divided into the following groups: Group I - Portland cement; Group II - Portland cement with iodoform (Portland cement + CHI3 ); Group III - Portland cement with zirconium oxide (Portland cement + ZrO2 ); and treated by pulpotomy technique (removal of a portion of the pulp aiming to maintain the vitally of the remaining radicular pulp tissue using a therapeutic dressing). Clinical and radiographic evaluations were recorded at 6, 12 and 24 months follow-up. The teeth at the regular exfoliation period were extracted and processed for histological analysis. Data were tested using statistical analysis with a significance level of 5%. The microscopic findings were descriptively analysed. All treated teeth were clinically and radiographically successful at follow-up appointments. The microscopic analysis revealed positive response to pulp repair with hard tissue barrier formation and pulp calcification in the remaining roots of all available teeth. The findings of this study suggest that primary teeth pulp tissue exhibited satisfactory biological response to Portland cement associated with radio pacifying agents. However, further studies with long-term follow-up are needed to determine the safe clinical indication of this alternative material for pulp therapy of primary teeth.

Expression of DMP-1 in the human pulp tissue using low level laser therapy

This study aimed to evaluate the effects of low-level laser therapy (LLLT) on DMP-1 expression in pulp tissue repair of human primary teeth. Twenty mandibular primary molars were randomly assigned into the following groups: Group I—Buckley’s Formocresol (FC); Group II—Calcium Hydroxide (CH); Group III—LLLT + CH and Group IV—LLLT + Zinc oxide/Eugenol. The teeth at the regular exfoliation period were extracted for histological analysis and immunolocalization of DMP-1. Descriptive analysis was performed on the dentin pulp complex. Histopathological assessment showed internal resorption in group FC. Groups CH and LLLT + CH provided better pulpal repair due to the absence of inflammation and the formation of hard tissue barrier. These two groups presented odontoblastic layer expressing DMP-1. According to this study, low level laser therapy preceding the use of calcium hydroxide exhibited satisfactory bio-inductive activity on pulp tissue repair of human primary teeth. However, other histological and cellular studies are needed to confirm the laser tissue action and efficacy.

Clinical and radiographic outcomes of the use of capping materials in vital pulp therapy of human primary teeth

Objective: The aim of this study was to compare the clinical and radiographic outcomes of Calcium Hydroxide (CH), Calcium Hydroxide preceded by corticosteroid/antibiotic solution (O+CH) and diluted formocresol (FC) in the vital pulp therapy of human primary teeth. Material and methods: Forty-five mandibular primary molars of children aged between 5-9 years were randomly assigned in the three study groups, FC, CH and O+CH and received conventional pulpotomy treatment. Clinical and radiographic follow-up was made at 3, 6 and 12-months. Results: No sign of clinical failure was observed in the three study groups during all the periods of evaluation. Radiographic analysis showed a total of six cases of internal root resorption in CH and O+CH groups after the 12 months follow-up, with statistically significant difference as compared with FC group. FC group did not show hard tissue barrier formation, that was observed in CH and O+CH groups in all the follow-up periods. Conclusion: All employed materials showed acceptable clinical and radiographic success rates. The results showed that the use of an anti-inflammatory solution prior the dressing material has therapeutic properties that help with pulpal healing. Continued clinical investigations using these medicaments as vital pulpotomy treatment in primary molars are recommended.

Evaluation of Bone Tissue Response to a Sealer Containing Mineral Trioxide Aggregate

IntroductionThis study analyzed bone tissue reactions to MTA Fillapex (Ângelus Industria de Produtos Odontológicos Ltda, Londrina, Brazil) compared with an epoxy resin–based material in the femur of Wistar rats. MethodsBone tissue reactions were evaluated in 15 animals after 7, 30, and 90 days (n = 5 per period). Three surgical cavities were prepared on the femur and filled with 0.2 mL MTA Fillapex, AH Plus (Dentsply DeTrey GmbH, Konstanz, Germany), or no sealer (negative control). By the end of each experimental period, 5 animals were randomly euthanized. The samples were histologically processed and analyzed using a light microscope. The presence of inflammatory cells, fibers, and hard tissue barrier formation was evaluated. Differences among the groups and between the 3 experimental periods were evaluated by using 2-way analysis of variance followed by the Bonferroni post hoc test (P ≤ .05). ResultsMTA Fillapex scored significantly higher for neutrophils at 7 days than at 90. At 7 days, the same occurred when comparing MTA Fillapex with AH Plus. The presence of lymphocytes/plasmocytes significantly decreased over time in all groups. Macrophages, giant cells, eosinophils, and fiber condensation presented no differences among groups and periods. Within 90 days, all groups presented complete hard tissue barrier formation. ConclusionsThe presence of mineral trioxide aggregate in MTA Fillapex composition did not improve the bone tissue repair. The presence of sealers provided the re-establishment of the original bone tissue structure and the inflammatory response decreased over time, so they can be considered biocompatible.

Antioxidant mix: A novel pulpotomy medicament: A scanning electron microscopy evaluation.

Aim:This study aims to evaluate the clinical, radiographic, and histological success rate of antioxidant mix as a new pulpotomy agent for primary teeth.Settings and Design:Commercially available antioxidants, namely Antioxidants plus trace elements (OXIn-Xttm, India) were used.Materials and Methods:This prospective study was carried out on 36 primary molar teeth in 32 children, with age that ranged from 6 to 9 years. Regular conventional pulpotomy procedure followed by placement of antioxidant mix over the radicular orifice was done. Recall was scheduled for 3, 6, and 9 months, respectively, after treatment.Results:Thirty-six pulpotomized primary molars were available for follow-up evaluations. Scanning electron microscopy analysis of samples showing convex shaped hard tissue barrier formation may be proof of the role of antioxidant material in localization and direction and morphology of the hard tissue barrier. One tooth which presented with pain was assessed as unsuccessful.Conclusion:Quite promising clinical, radiographic, and histological results of antioxidants in the present study shows their potential to be an ideal pulpotomy agent.

Comparative evaluation of formocresol and mineral trioxide aggregate as pulpotomy agents in deciduous teeth

To evaluate and compare mineral trioxide aggregate (MTA) and formocresol as pulpotomy medicaments by clinical and radiographic assessments and to assess the histological features of both pulpotomy medicaments in deciduous teeth. This study was performed on 100 mandibular deciduous molar teeth requiring pulpotomy treatment. Children between age four and six years were randomly selected and divided into formocresol or MTA group. The patients were recalled after 3, 6, 9, 12 months respectively and evaluated clinically and radiographically. Histological assessment was done on lower deciduous canine teeth, which were undergoing serial extraction for interceptive orthodontic purpose. Pulpotomy was done on four teeth with formocresol and another four teeth with MTA. The teeth were extracted after six months following pulpotomy procedure and histologically evaluated. Two freshly extracted carious teeth were taken as controls. Clinical and radiographic criteria were laid and Chi analysis revealed significant difference in mobility ( P≤0.05), periodontal ligament widening ( P≤0.01 level) and inter - radicular radiolucency ( P≤0.02 level) between two groups at the end of 12 months. Histologically, in MTA group, a layer of new dentine formation with less dentinal tubules at the pulpotomized site was found. In formocresol group, increased inflammatory cells, a zone of atrophy, were noted in radicular portion of pulp. MTA is superior to formocresol clinically, radiographically. Histological analysis showed better reparative ability with hard tissue barrier formation with MTA compared to formocresol.

Cytotoxicity and biocompatibility of direct and indirect pulp capping materials

There are several studies about the cytotoxic effects of dental materials in contact with the pulp tissue, such as calcium hydroxide (CH), adhesive systems, resin composite and glass ionomer cements. The aim of this review article was to summarize and discuss the cytotoxicity and biocompatibility of materials used for protection of the dentin-pulp complex, some components of resin composites and adhesive systems when placed in direct or indirect contact with the pulp tissue. A large number of dental materials present cytotoxic effects when applied close or directly to the pulp, and the only material that seems to stimulate early pulp repair and dentin hard tissue barrier formation is CH.

Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial

To investigate the pulpal response to direct pulp capping in healthy human teeth with mineral trioxide aggregate (MTA) as against calcium hydroxide cement (Dycal) as control. Twenty healthy human third molars had iatrogenic pulpotomy and direct pulp capping with MTA. Another 13 teeth were capped with Dycal as controls. The teeth were restored, with IRM, clinically reviewed and extracted after a number of pre-determined intervals (1 week, 1 month and 3 months). The specimens were fixed, decalcified, subdivided axially into two halves in the oro-buccal (lingual-buccal) plane, embedded in plastic, serial sectioned and evaluated qualitatively and quantitatively by correlative light and transmission electron microscopy with appropriate statistical evaluation of the quantitative data. Iatrogenic pulpal wounds treated with MTA were mostly free from inflammation after 1 week and became covered with a compact, hard tissue barrier of steadily increasing length and thickness within 3 months following capping. Control teeth treated with Dycal revealed distinctly less consistent formation of a hard tissue barrier that had numerous tunnel defects. The presence of pulpal inflammation up to the longest observation period (3 months) after capping, was a common feature in Dycal specimens. The MTA was clinically easier to use as a direct pulp-capping agent and resulted in less pulpal inflammation and more predictable hard tissue barrier formation than Dycal. Therefore, MTA or equivalent products should be the material of choice for direct pulp capping procedures instead of hard setting calcium hydroxide cements.

Importance of the diagnosis in the pulpotomy of immature permanent teeth

Pulpotomy is a conservative therapy performed to remove the inflamed coronal portion of the pulp and preserve the vitality of the remaining radicular pulp. This article reports two cases of immature permanent mandibular molars with clinical signs of pulp vitality and radiographic images of periapical bone rarefaction, which were treated with calcium hydroxide pulpotomy. In Case 1, pulpotomy was performed in a single session, while in Case 2 two sessions were required to complete the treatment. Clinical and radiographic follow up within 13 and 9 months, respectively, showed hard tissue barrier and new bone formation as well as progression of root development. These outcomes are confirmatory that an accurate clinical/radiographic assessment of pulp vitality is of paramount importance for the correct diagnosis and indication of pulpotomy in cases of young permanent teeth with incomplete root formation.

Hard tissue barrier formation after pulp capping?

Searches for relevant studies were made using Medline and the Cochrane Controlled Trials Register (CENTRAL). Reference lists of identified articles were searched. Studies selected were those carried out on human teeth, with or without caries, that were treated using a pulp-capping procedure and where the hard tissue and pulp were analysed with the aid of a microscope. Reviews of pulp capping were searched for references. The authors independently extracted the data and assessed the level of evidence of each publication as high, moderate or low. Based on this, the evidence grade of the conclusions was rated as strong, moderately strong, limited or insufficient. Of 107 studies identified, 21 met the selection criteria. No study had a high level of evidence, one study was moderate and 20 studies provided a low level of evidence. There was heterogeneity between the studies and therefore no meta-analysis was performed. The majority of studies on pulp capping using calcium hydroxide-based materials reported formation of hard tissue bridging: studies on other pulp capping materials such as bonding agents presented inferior results. Although the majority of studies using calcium hydroxide-based materials reported hard tissue bridging, the quality of the available evidence is low. There is a need for more high-quality studies.