Mineral trioxide aggregate as a pulpotomy medicament: A narrative review

  • F. K. Ng
  • L. B. MesserEmail author


Background: Several medicaments have been used to devitalize remaining pulp or maintain pulp vitality and promote healing. Based on pulpal biocompatibility and good sealing ability, a growing interest in more biocompatible materials promotes mineral trioxide aggregate (MTA) as an alternative to traditional medicaments. Uniquely, MTA can preserve pulpal health predictably and promote healing with pulp regeneration. Methods: Using electronic search all papers published since 1993 on the use of MTA in paediatric dentistry were identified. This paper provides a narrative review of the current literature on MTA, formocresol, ferric sulphate and calcium hydroxide with particular reference to primary teeth pulpotomy medication. Conclusion: The use of formocresol or formaldehyde-based medicaments should be replaced with more biocompatible medicaments possessing antimicrobial and pulpal regenerative properties. Of the four pulpotomy medicaments discussed, mineral trioxide aggregate is recommended as the medicament of choice.

Key words

Pulp therapy dental materials mineral trioxide aggregate formocresol ferric sulphate 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS. Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp capping agents in human teeth: a preliminary report. Int Endod J 2002;36:225–31.CrossRefGoogle Scholar
  2. Aeinehchi M, Dadvand S, Fayazi S, Bayat-Movahed S. Randomized controlled trial of mineral trioxide aggregate and formocresol for pulpotomy in primary molar teeth. Int Endod J 2007;40:261–7.PubMedCrossRefGoogle Scholar
  3. Agamy HA, Bakry NS, Mounir MMF, Avery DR. Comparison of mineral trioxide aggregate and formocresol as pulp capping agents in pulpotomized primary teeth. Pediatr Dent 2004;26:302–9.PubMedGoogle Scholar
  4. Alacam A. Pulpal tissue changes following pulpotomies with formocresol, glutaraldehyde-calcium hydroxide, glutaraldehyde-zinc oxide eugenol pastes in primary teeth. J Pedod 1989;13:123–32.PubMedGoogle Scholar
  5. Al-Hezaimi K, Naghshbandi J, Oglesby S, Simon JHS, Rotstein I. Human saliva penetration of root canals obturated with two types of mineral trioxide aggregate cements. J Endod 2005;31:453–6.PubMedCrossRefGoogle Scholar
  6. American Academy of Pediatric Dentistry. Guideline on pulp therapy for primary and young permanent teeth. Pediatr Dent 2007-8;29 [Reference manual]:163–7.Google Scholar
  7. Aminoshariae A, Hartwell GR, Moon PC. Placement of mineral trioxide aggregate using two different techniques. J Endod 2003;29:679–82.PubMedCrossRefGoogle Scholar
  8. Asgary S, Parirokh M, Eghbal MJ, Brink F. Chemical differences between white and grey mineral trioxide aggregate. J Endod 2005;31:101–3.PubMedCrossRefGoogle Scholar
  9. Australasian Academy of Paediatric Dentistry (Inc.). Guidelines for pulp therapy for primary and young permanent teeth. 1st ed. 2002;29–30.Google Scholar
  10. Berger JE. Pulp tissue reaction to formocresol and zinc oxide-eugenol. ASDC J Dent Child 1965;32:13–28.PubMedGoogle Scholar
  11. Caicedo R, Abbott PV, Alongi DJ, Alarcon MY. Clinical, radiographic and histological analysis of the effects of mineral trioxide aggregate used in direct pulp capping and pulpotomies of primary teeth. Aust Dent J 2006;51:297–305.PubMedCrossRefGoogle Scholar
  12. Camilleri J, Montesin FE, Papaioannou S, McDonald F, Pitt Ford TR. Biocompatibility of two commercial forms of mineral trioxide aggregate. Int Endod J 2004;37:699–704.PubMedCrossRefGoogle Scholar
  13. Camilleri J, Montesin FE, Brady K et al. The constitution of mineral trioxide aggregate. Dent Mater 2005;21:297–303.PubMedCrossRefGoogle Scholar
  14. Camilleri J, Pitt Ford TR. Mineral trioxide aggregate: a review of the constituents and biological properties of the material. Int Endod J 2006;39:747–54.PubMedCrossRefGoogle Scholar
  15. Casas MJ, Kenny DJ, Johnston DH, Judd PL. Long-term outcomes of primary molar ferric sulfate pulpotomy and root canal therapy. Pediatr Dent 2004;26:44–8.PubMedGoogle Scholar
  16. Cotes O, Boj JR, Canalda C, Carreras M. Pulpal tissue reaction to formocresol vs ferric sulfate in pulpotomized rat molars. J Clin Pediatr Dent 1997;21:247–53.PubMedGoogle Scholar
  17. Cox CF, Subay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in dentin bridges: their formation following direct pulp capping. Oper Dent 1996;21:4–11.PubMedGoogle Scholar
  18. Cuisia ZE, Musselman R, Schneider P, Dumett CJR. A study of mineral trioxide aggregate pulpotomies in primary molars. Pediatr Dent 2001;23:168.Google Scholar
  19. Dominguez MS, Witherspoon DE, Gutmann JL, Opperman LA. Histological and scanning electron microscopy assessment of various vital pulp therapy materials. J Endod 2003;29:324–33.PubMedCrossRefGoogle Scholar
  20. Doyle WA, McDonald RE, Mitchell DF. Formocresol versus calcium hydroxide in pulpotomy. J Dent Child 1962;29:86–97.Google Scholar
  21. Duggal MS, Nooh A, High A. Response of the primary pulp to inflammation: a review of the Leeds studies and challenges for the future. Eur J Paediatr Dent 2002;3:111–4.PubMedGoogle Scholar
  22. Economides N, Pantelidou O, Kokkas A, Tziafas D. Short-term periradicular tissue response to mineral trioxide aggregate (MTA) as root end filling material. Int Endod J 2003;36:44–8.PubMedCrossRefGoogle Scholar
  23. El-Meligy OA, Avery DR. Comparison of mineral trioxide aggregate and calcium hydroxide as pulpotomy agents in young permanent teeth (apexoge-nesis). Pediatr Dent 2006;28:399–404.PubMedGoogle Scholar
  24. Faraco Jr IM, Holland R. Response of the pulp of dogs to capping with mineral trioxide aggregate or a calcium hydroxide cement. Dent Traumatol 2001;17:163–6.PubMedCrossRefGoogle Scholar
  25. Farsi N, Alamoudi N, Balto K, Mushayt A. Success of mineral trioxide aggregate in pulpotomized primary molars. J Clin Pediatr Dent 2005;29:307–11.PubMedGoogle Scholar
  26. Ferris DM, Baumgartner JC. Perforation repair comparing two types of mineral trioxide aggregate. J Endod 2004;30:422–4.PubMedCrossRefGoogle Scholar
  27. Fischer EJ, Arens DE, Miller CH. Bacterial leakage of mineral trioxide aggregate as compared with zinc free amalgam, intermediate restorative material and super-EBA as a root-end filling material. J Endod 1998;24:176–9.PubMedCrossRefGoogle Scholar
  28. Fridland M, Rosado R. MTA Solubility: A long term study. J Endod 2005;31:376–9.PubMedCrossRefGoogle Scholar
  29. Fuks AB, Bimstein E, Bruchim A. Radiographic and histologic evaluation of the effect of two concentrations of formocresol on pulpotomized primary and young permanent teeth in monkeys. Pediatr Dent 1983;5:9–13.PubMedGoogle Scholar
  30. Fuks AB, Eidelman E, Cleaton-Jones P, Michaeli Y. Pulp response to ferric sulfate, diluted formocresol and IRM in pulpotomized primary baboon teeth. ASDC J Dent Child 1997:64:254–9.PubMedGoogle Scholar
  31. Fuks AB. Pulp therapy for the primary and young permanent dentitions. Dent Clin North Am 2000;44:571–96.PubMedGoogle Scholar
  32. Fuks AB, Papagiannoulis L. Pulpotomy in primary teeth: review of the literature according to standardized assessment criteria. Eur Arch Paediatr Dent 2006;7:64–71.PubMedCrossRefGoogle Scholar
  33. Garcia-Godoy F, Novakovic DP, Carvajal IN. Pulpal response to different application times of formocresol. J Pedod 1982;6:176–93.PubMedGoogle Scholar
  34. Goldmacher VS, Thilly WD. Formaldehyde is mutagenic for cultured human cells. Mutat Res 1983;116:417–22.PubMedCrossRefGoogle Scholar
  35. Goracci G, Mori G. Scanning electron microscopic evaluation of resin-dentin and calcium hydroxide-dentin with resin composite restorations. Quintessence Int 1996; 27:129–35.PubMedGoogle Scholar
  36. Gruythuysen RJ, Weerheijm KL. Calcium hydroxide pulpotomy with a light cured cavity sealing material after two years. J Dent Child 1997;64:251–3.Google Scholar
  37. Hachmeister DR, Schindler WG, Walker WA, Thomas DD. The sealing ability and retention characteristics of mineral trioxide aggregate in a model of apexification. J Endod 2002;28:386–90.PubMedCrossRefGoogle Scholar
  38. Holan G, Fuks AB, Keltz N. Success rate of formocresol pulpotomy in primary molars restored with stainless steel crown vs amalgam. Pediatr Dent 2002;24:212–6.PubMedGoogle Scholar
  39. Holan G, Eidelman E, Fuks AB. Long term evaluation of pulpotomy in primary molars using mineral trioxide aggregate or formocresol. Pediatr Dent 2005;27:129–36.PubMedGoogle Scholar
  40. Huang TH, Yang CC, Ding SJ et al. Inflammatory cytokines reaction elicited by root-end filling materials. J Biomed Mater Res 2005;73:123–8.CrossRefGoogle Scholar
  41. Huth KC, Paschos E, Hajek-Al-Khatar N et al. Effectiveness of 4 pulpotomy techniques-randomized controlled trial. J Dent Res 2005;84:1144–8.PubMedCrossRefGoogle Scholar
  42. Ibricevic H, Al-Jame Q. Ferric sulphate and formocresol in pulpotomy of primary molars: long term follow-up study. Eur J Paediatr Dent 2003;4:28–32.PubMedGoogle Scholar
  43. International Agency for Research on Cancer. Press release no. 153, 15 June 2004. Available at: Accessed 8 Aug 2007.
  44. Jabbarifar SE, Khademi DD, Ghasemi DD. Success rates of formocresol pulpotomy versus mineral trioxide aggregate in human primary molar tooth. J Res Med Sci 2004;6:55–8.Google Scholar
  45. Kratchman SI. Perforation repair and one-step apexification procedures. Dent Clin North Am 2004;48:291–307.PubMedCrossRefGoogle Scholar
  46. Loh A, O’Hoy P, Tran X et al. Evidence-based assessment: Evaluation of the formocresol verus ferric sulfate primary molar pulpotomy. Pediatr Dent 2004;26:401–9.PubMedGoogle Scholar
  47. Mangin C, Yesilsoy C, Nissan R, Stevens R. The comparative sealing ability of hydroxyapatite cement, mineral trioxide aggregate, and super ethoxy-benzoic acid as root-end filling materials. J Endod 2003;29:261–4.PubMedCrossRefGoogle Scholar
  48. Markovic D, Zivojinovic V, Vucetic M. Evaluation of three pulpotomy medicaments in primary teeth. Eur J Paediatr Dent 2005;6:133–8.PubMedGoogle Scholar
  49. Maroto M, Barberia E, Pianeils P, Garcia-Godoy F. Dentin bridge formation after mineral trioxide aggregate (MTA) pulpotomies in primary teeth. Am J Dent 2005;18:151–4.PubMedGoogle Scholar
  50. Martell B, Chandler NP. Electrical and dye leakage comparison of three root-end restorative materials. Quintessence Int 2002;33:30–4.PubMedGoogle Scholar
  51. Matt GD, Thorpe JR, Strother JM, McClanahan SB. Comparative study of white and grey mineral trioxide aggregate (MTA) simulating a one- or two-step apical barrier technique. J Endod 2004;30:876–9.PubMedCrossRefGoogle Scholar
  52. Milnes AR. Persuasive evidence that formocresol use in pediatric dentistry is safe. J Can Dent Assoc 2006;72:247–8.PubMedGoogle Scholar
  53. Mitchell PJ, Pitt Ford TR, Torabinejad M, McDonald F. Osteoblast biocompatibility of mineral trioxide aggregate. Biomaterials 1999;20:167–73.PubMedCrossRefGoogle Scholar
  54. Mjor IA, Dahl E, Cox CF. Healing of pulp exposures: an ultrastructural study. J Oral Pathol Med 1991;20:496–501.PubMedCrossRefGoogle Scholar
  55. Nadin G, Goel BR, Yeung CA, Glenny AM. Pulp treatment for extensive decay in primary teeth. Cochrane Database Syst Rev. 2003;1:CD0033220.Google Scholar
  56. Naik S, Hegde AM. Mineral trioxide aggregate as a pulpotomy agent in primary molars: An in vivo study. J Indian Soc Pedod Prev Dent 2005;23:13–16.PubMedCrossRefGoogle Scholar
  57. Ng FK. An evidence-based assessment on the effectiveness of four primary molar pulpotomy medicaments [DClinDent thesis]. Victoria, Australia: The University of Melbourne; 2007.Google Scholar
  58. Ng FK, Messer LB. Mineral trioxide aggregate as a pulpotomy medicament: An evidence-based assessment. J Dent Res [IADR ANZ division 2007-Abstract 0.35].Google Scholar
  59. Papagiannoulis L. Clinical studies on ferric sulphate as a pulpotomy medicament in primary teeth. Eur J Paediatr Dent 2002;3:126–32.PubMedGoogle Scholar
  60. Parirokh M, Asgary S, Eghbal MJ, Stowe S, Eslami B, Eskandarizade A, Shabahang S. A comparative study of white and grey mineral trioxide aggregate as pulp capping agents in dog’s teeth. Dent Traumatol 2005;21:150–4.PubMedCrossRefGoogle Scholar
  61. Peng L, Ye L, Tan H, Zhou X. Evaluation of the formocresol versus mineral trioxide aggregate primary molar pulpotomy: a meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:40–4.CrossRefGoogle Scholar
  62. Qudeimat MA, Barrieshi-Nusair KM, Owais AI. Calcium hydroxide vs. mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries. Eur Arch Paediatr Dent 2007;8:99–104.PubMedCrossRefGoogle Scholar
  63. Ranly DM, Horn D. Assessment of systemic distribution and toxicity of formaldehyde following pulpotomy treatment: Part Two. J Dent Child 1987;54:40–4.Google Scholar
  64. Ranly DM. Pulpotomy therapy in primary teeth: new modalities for old rationales. Pediatr Dent 1994;16:403–9.PubMedGoogle Scholar
  65. Ranly D, Garcia-Godoy F. Current and potential pulp therapies for primary and young permanent teeth. J Dent 2000;28:153–61.PubMedCrossRefGoogle Scholar
  66. Rocha M, Baroni R, Santos L, Girardi K. Ca(OH)2 and MTA pulpotomies in primary teeth: one year results. Int J Paediatr Dent 1999;9(Suppl 1):102 [Abstr P5.35].Google Scholar
  67. Rodd HD, Waterhouse PJ, Fuks AB, Fayle SA, Moffat MA. Pulp therapy for primary molars. UK National Clinical Guidelines in Paediatric Dentistry. Int J Paediatr Dent 2006;16[Suppl 1]:15–23.PubMedCrossRefGoogle Scholar
  68. Rolling I, Thylstrup A. A 3 year follow-up study of pulpotomized primary molars treated with the formocresol technique. Scand J Dent Res 1975;83:47–53.PubMedGoogle Scholar
  69. Rolling I, Hasselgren G, Tronstad L. Morphologic and enzyme histochemical observations on the pulp of human primary molars 3–5 years after formocresol treatment. Oral Surg Oral Med Oral Pathol 1976;42:518–28.PubMedCrossRefGoogle Scholar
  70. Saidon J, He J, Zhu Q, Safavi K, Spangberg LSW. Cell and tissue reactions to mineral trioxide aggregate and Portland cement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:483–9.PubMedCrossRefGoogle Scholar
  71. Salako N, Joseph B, Ritwik P, Salonen J, John P, Junaid TA. Comparison of bioactive glass, mineral trioxide aggregate, ferric sulfate and formocresol as pulpotomy agents in rat molars. Dent Traumatol 2003;19:314–20.PubMedCrossRefGoogle Scholar
  72. Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of biological properties of mineral trioxide aggregate. J Endod 2005;31:97–100.PubMedCrossRefGoogle Scholar
  73. Schroder U, Granath LE. Early reaction of intact human teeth to calcium hydroxide following experimental pulpotomy and its significance to the development of hard tissue barrier. Odont Revy 1971;22:379–96.Google Scholar
  74. Schroder U. Effect of an extra-pulpal blood clot on healing following experimental pulpotomy and capping with calcium hydroxide. Odont Revy 1973;24:257–68.Google Scholar
  75. Schroder U. A 2-year follow-up of primary molars, pulpotomised with a gentle technique and capped with calcium hydroxide. Scand J Dent Res 1978;86:273–8.PubMedGoogle Scholar
  76. s-Gravenmade EJ. Some biochemical considerations of fixation in endodontics. J Endod 1975;1:233–7.CrossRefGoogle Scholar
  77. Shahi S, Rahimi S, Lotfi M, Yavari HR, Gaderian AR. A comparative study of the biocompatibility of three root-end filling materials in rat connective tissue. J Endod 2006:32:776–80.PubMedCrossRefGoogle Scholar
  78. Shipper G, Grossman ES, Botha AJ, Cleaton-Jones PE. Marginal adaptation of mineral trioxide aggregate (MTA) compared with amalgam as a root-end filling material: a low vacuum (LV) versus high vacuum (HV) SEM study. Int Endod J 2004;37:325–36.PubMedCrossRefGoogle Scholar
  79. Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars: a retrospective study. Pediatr Dent 2000;22:192–9.PubMedGoogle Scholar
  80. Spencer DL. Physical properties of a new mineral trioxide aggregate material. [M.Sc thesis]. Richmond, Virginia: Virginia Commonwealth University; 2004.Google Scholar
  81. Srinivasan V, Patchett CL, Waterhouse PJ. Is there life after Buckley’s formocresol? Part I-A narrative review of alternative interventions and materials. IntJ Paediatr Dent 2006;16:117–27.CrossRefGoogle Scholar
  82. Stanley HR. Pulp capping: conserving the dental pulp-Can it be done? Is it worth it? Oral Surg Oral Med Oral Pathol 1989;68:628–39.PubMedCrossRefGoogle Scholar
  83. Subay RK, Suzuki S, Suzuki S, Kaya H, Cox CF. Human pulp response after partial pulpotomy with two calcium hydroxide products. Oral Surg Oral Med Oral Pathol 1995;80:330–7.CrossRefGoogle Scholar
  84. Swenberg JA, Kerns WD, Mitchell RJ, Gralla EJ, Pavkov KL. Induction of squamous cell carcinoma of the rat nasal cavity by inhalation exposure to formaldehyde vapour. Cancer Res 1980;40:3398–402.PubMedGoogle Scholar
  85. Tang HM, Torabinejad M, Kettering JD. Leakage evaluation of root end filling materials using endotoxin. J Endod 2002;28:5–7.PubMedCrossRefGoogle Scholar
  86. Thomson TS, Berry JE, Somerman MJ, Kirkwood KL. Cementoblasts maintains expression of osteocalcin in the presence of mineral trioxide aggregate. J Endod 2003;29:407–12.PubMedCrossRefGoogle Scholar
  87. Torabinejad M, Higa RK, McKendry DJ, Pitt Ford TR. Dye leakage of four root-end filling materials: effects of blood contamination. J Endod 1994;20:159–63.PubMedCrossRefGoogle Scholar
  88. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root-end filling material. J Endod 1995a;21:349–53.PubMedCrossRefGoogle Scholar
  89. Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Antibacterial effects of some root-end filling materials. J Endod 1995b;21:403–6.PubMedCrossRefGoogle Scholar
  90. Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR, Miller DA, Kariyawasen SP. Histological assessment of MTA as root end filling in monkeys. J Endod 1997;23:225–8.PubMedCrossRefGoogle Scholar
  91. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197–205.PubMedCrossRefGoogle Scholar
  92. Tziafas D, Pantelidou O, Alvanou A, Belibasakis G, Papadimitriou S. The dentinogenic activity of mineral trioxide aggregate (MTA) in short term capping experiments. Int Endod J 2002;35:245–54.PubMedCrossRefGoogle Scholar
  93. Valois CRA, Costa Junior ED, Brazil B. Influence of the thickness of mineral trioxide aggregate on sealing ability of root-end fillings in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:108–11.PubMedCrossRefGoogle Scholar
  94. Vij R, Coll JA, Shelton P, Farooq NS. Caries control and other variables associated with success of primary molar vital pulp therapy. Pediatr Dent 2004;26:214–20.PubMedGoogle Scholar
  95. Waterhouse PJ, Nunn JH, Whitworth JM. An investigation of the relative efficacy of Buckley’s formocresol and calcium hydroxide in primary molar vital pulpotomy. Brit Dent J 2000;188:32–6.PubMedGoogle Scholar
  96. Williams D. Revisiting the definition of biocompatibility. Med Device Technol 2003;14:10–3.Google Scholar
  97. Wu MK, Kontakiotis EG, Wesselink PR. Discoloration of 1% methylene blue solution in contact with dental filling materials. J Dent 1998;26:585–9.PubMedCrossRefGoogle Scholar
  98. Yaltirik M, Ozbas H, Bilgic B, Issever H. Reactions of connective tissue to mineral trioxide aggregate and amalgam. J Endod 2004:30:95–9.PubMedCrossRefGoogle Scholar
  99. Zander HA. Reaction of the pulp to calcium hydroxide. J Dent Res 1939;18:373–9.CrossRefGoogle Scholar

Copyright information

© European Academy of Paediatric Dentistry 2008

Authors and Affiliations

  1. 1.Paediatric Dentistry, School of Dental ScienceThe University of MelbourneMelbourne, CarltonAustralia

Personalised recommendations