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Essay: BioDentine – dentine substitute material in endodontic procedures, compared to MTA

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  • BioDentine - dentine substitute material in endodontic procedures, compared to MTA
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Biodentine:

Usually, Biodentine is present as a capsule containing the ideal ratio of powder and liquid. The liquid contains calcium chloride which acts as an accelerator, hydro soluble polymer functions as water reducing agent and water. The powder contains Tricalcium silicate (3CaO.SiO2) (main core material), Dicalcium silicate (2CaO.SiO2) (second core material), Calcium carbonate (CaCO2) (filler), Zirconium Oxide (ZrO2) (radio-opacifier) and Iron oxide (coloring agent) (Table 1).

2.1.b. MTA (Mineral Trioxide Aggregate)

It is the Mechanical mixture of three powder ingredients: Portland cement (75%), bismuth oxide (20%) and gypsum (5%). It consists of calcium oxide (50-75%) and silicon oxide (15-20%) which together constitute 70-95% of the cement. Tricalcium silicate, dicalcium silicate, tricalcium aluminate, tetracalcium aluminoferrite are produced upon mixing (Table1). There are grey and white MTA due to the presence of iron that forms the tetracalciumalumino-ferrite phase.

2.2- Setting reaction:

2.2.a. Biodentine:

Calcium silicate particles form a high pH solution when reacting with water. This solution contains Ca2+, OH- and silicate ions. The hydration of the tricalcium silicate leads to the formation of a hydrated calcium silicate gel on the cement particles and calcium hydroxide nucleates. With the passage of time, calcium silicate hydrated gel polymerizes to form a solid network and the alkalinity of the surrounding medium increases due to the release of calcium hydroxide ions. Further the hydrated calcium silicate gel surrounds the unreacted tricalcium silicate particles and due to its relatively impermeable nature to water, it helps in slowing down the effects of further reactions.
2(3CaO.SiO2) + 6H2O→ 3CaO.2SiO2.3H2O + 3Ca(OH)2

2.2.b. MTA:

Hydration reaction between tricalcium silicate and dicalcium silicate to form a calcium hydroxide and calcium silicate hydrate gel producing an alkaline pH. A further reaction between tricalcium aluminate and calcium phosphate forms a high-sulphate calcium sulphoaluminate. The calcium ions leach through the dentinal tubules and the concentration increases with time as the material cures.

2.3- Setting time:

Biodentine has a short setting time because of the presence of an accelerator (Calcium Chloride) (Table 2).

2.4- Density and Porosity:

They are the critical factors that determines the amount of leakage and outcome of the treatment. The greater the pores’ diameter the more the leakage. Biodentine exhibits lower porosity than MTA (Table 1).

2.5- Compressive strength:

During the setting of Biodentine, the compressive strength increases 100 MPa in the first hour and 200 MPa at 24th hour and it continues to improve with time over several days until reaching 300 MPa after one month. A study done by Grech et al., showed that Biodentine had the highest compressive strength when compared to other tested materials due to low water/cement ratio used in Biodentine.

2.6- Flexural strength:

It is an important factor as it decreases the risk of fracture. Walker MP et al., observed that the flexural strength of MTA after 24 hours is 14.27 MPa. On the other hand, the flexural strength of Biodentine after 2 hours is recorded to be 34 MPa.

2.7- Microhardness:

The microhardness of MTA is affected by: the pH, the thickness of the material, the condensation pressure, the amount of entrapped air in the mixture, humidity, acid etching of the material, and temperature. Biodentine showed superior value of microhardness because the crystallization of calcium silicate hydrate gel continues, which reduces porosity and increase hardness with time.

2.8- Radiopacity:

The mean radiopacity for MTA has been found to be 7.17 mm of aluminum and Biodentine reported a radiopacity to 3.5 mm of aluminum.

2.9- Solubility:

Porosity characteristics {density (g/cm3)} Final

Setting time Initial setting time Materials

2.260 10.1 min 6 min Biodentine

1.882 175 min 70 min MTA

There is no definite conclusion regarding the MTA solubility, and it was concluded that increase in water-to-powder ratio will increase the release of calcium from MTA which increase the solubility. However, Grech et al., reported lowest degree of solubility for Biodentine.

2.10 – Bond Strength & Push out bond strength:

Tunc ES et al., observed that using a total etch adhesive system with composite and compomer over MTA resulted in a higher bond strength than with a one-step self-etch adhesive system. Hashem et al., also reported that Biodentine exhibited low initial bond strength, so it was advisable to delay the application of the final composite restoration for more than two weeks, to allow it to achieve good bond strength to resist composite shrinkage.

Push Out Bond strength is the strength of the material that allows it to resist dislodgement. Guneser ME et al., studied that MTA had a lower push out bond strength than Biodentine.

2.11- Discoloration:

Because of its content (Bismuth oxide) MTA undergoes significant color change (yellow) while Biodentine exhibits higher color stability for five days. (Valles M et al)

Biodentine in comparison to MTA

Bioactivity & ability to induce tertiary dentin synthesis. Stimulates cementoblasts and cementum formation.

Better handling & manipulation (Better consistency) Less than BD, but superior to other traditional root-end fillings

Less leakage than MTA (0.149)* More leakage than BD (0.583)*

Has shorter setting time  less chance of contamination. 2 hrs and 45 min

Does not require two step procedure. Setting time is long, temporary restoration is needed. (2-steps)

2.12 – Biocompatibility:

When comparing MTA, Biodentine and GIC, Zhou H et al., concluded that MTA & Biodentine caused similar reactions, but both were less cytotoxic than GIC.

2.13 – Bioactivity:

Laurent P et al., reported that secretion of growth factor (TGF-b1) increased with Biodentine in comparison to MTA, which induced synthesis of reparative dentin. TGF-b1 or Transforming Growth Factor Beta 1 is an important cytokine to induce differentiation of ectomesenchymal cells into odontoblasts to produce reparative dentine.

3.Biodentine as a Dentine Replacement Material

Biodentine was considered the first all-in-one bioactive and biocompatible dentine substitute that can be used to treat damaged dentine.
Biodentine doesn’t require any conditioning of the dentine’s surface prior its application. Its micromechanical retention is achieved through the penetration of the material into the dentinal tubules forming tag-like structures. Unlike resin-based dentine replacement materials, Biodentine can be used in bulk thus preventing layering and interface that could cause microleakage or restoration failure.
Restorative Clinical applications include using Biodentine as an immediate enamel restoration, it is placed in the cavity preparation so that the volume of missing dentin is replaced. If a matrix is used, it should not be removed before the setting time. The permanent enamel restoration should be placed at the end of the setting time. Or as a non-immediate enamel restoration, in which the occlusal portion of the restoration would be removed within 1 week to 6 months and a permanent restoration (amalgam, composite, etc.) is placed. The compressive strength of Biodentine increases with time and will be strong enough to withstand chewing after a few hours.

Biodentine is a good candidate for a dentine substitute in open sandwich restorations because it does not require photoactivation and thus can be placed in bulk in the cavity. And finally, the use of acid etchant for Biodentine, in 2014,

Table 2 Comparison between BioDentine and MTA.

Odabaş et al evaluated the bond strength of Biodentine with different etching systems. There was no difference found when tested at the same time intervals (12 minutes and 24 hours). On the other hand, different time intervals showed that the etch and rinse adhesive had the lowest bond strength at 12 minutes while the 2-step self-etch had the highest with the 24-hour duration. Another study done in 2013 by Josette Camilleri proved that total etch, and rinse was more effective than self- etch.

4.BioDentine in Direct & Indirect Pulp Capping procedures:

4.1 Direct Pulp Capping

Direct pulp capping is a treating procedure of an exposed pulp using dental materials that promotes the formation of tertiary (reparative) dentine and maintenance of pulp. It can also be considered as an alternative way to avoid vital pulp excision. However, vital pulp excision success rate is much higher than the direct pulp capping. Before treatment, the pulp should be asymptomatic as in clear from bacteria or toxins, and bleeding should be controlled by sodium hypochlorite for example. Any remnants might cause treatment failure. A study was done on the maxillary and mandibular sound 3rd molars of twenty-eight patients for 6 weeks, and pulp vitality was examined prior extraction. After teeth cleaning, disinfection, local anesthesia and rubber dam are applied, class 1 cavities were prepared and an exposure around 1.2 mm in diameter was done. The teeth were divided into Biodentine and MTA experimental groups and one control group for comparison. Within a week, patients returned for the application of the final composite restoration. After 6 weeks, teeth were extracted. After extraction teeth were fixed and demineralized, then samples were evaluated under normal and ultraviolet light. The results showed that the pulp-dentin response was the same in both groups, where dentin bridge was formed directly under the capping material in site of exposure. Odontoblast cells near dentinal bridge were discovered with dentinal tubules. In conclusion Biodentine is considered an alternative material to MTA in treating vital pulps. However, further studies are needed to assess the mode of action of Biodentine on the pulp.

4.2 Indirect Pulp Capping

Indirect pulp capping is a non-invasive and conservative procedure that maintains pulp vitality on normal or reversibly inflamed pulp. It’s simple and less expensive compared to other pulp treatments. It involves removing the soft infected dentin that can’t be remineralised and is infiltrated with bacteria. The deepest layer of dentin is left on the unexposed pulp, then a biocompatible liner is placed. It reduces the risk of pulp exposure and caries progression. A randomized clinical trial was published to compare the efficiency of biodentine and calcium hydroxide for indirect pulp capping on carious molars. The samples involved 80 healthy children with deep carious lesions. Participants received local anesthesia and rubber dam isolation. Success of the material was evaluated by the clinical/radiographic appearance to note out any failures. There was no statistically significant difference between the two liners and therefore the null hypothesis is not rejected. As a result, many consider indirect pulp capping to be a non-material dependent technique. Biodentine has excellent properties compared to calcium hydroxide; it induces the formation of reparative tertiary dentin due to odontoblastic proliferation as well as the formation of mineralized tissue bridge and the ability to produce a marginal seal.

5.Cavity sealing

The marginal integrity of biodentine is due to multiple factors. Primarily, the formation of hydroxyapatite crystals on the surface of dentinal walls due to the release of calcium and silicon ions from the material. The sealing ability is also achieved by the formation of apatite deposits through the interaction of calcium silicate-based material with the phosphate ions of saliva. Moreover, the nanostructure of the forming gel of biodentine allows the spread of the material resulting in an improved sealing ability, also its minimal expansion property improved the adaptation of the material.

Although when its used as a (liner or a base), leakage of biodentine should be considered because it may lead to sensitivity, secondary caries and finally results in treatment failure.

A study was made to compare between cavity sealing of tooth filled with biodentine manually triturated or by machine trituration. More microleakage was seen when Biodentine was manually manipulated as compared to machine trituration and that is because mechanical trituration produces a more homogenous mix compared to manual mixing.

6.Antibacterial and Antifungal activity:

A study aimed to evaluate the antibacterial and antifungal properties of Biodentine, compared to commercial glass ionomer cements (GICs) and mineral trioxide aggregate (MTA).

Growth inhibition diameter around each material was recorded after they were fixed in seeded plates. Records were taken within 24-72 hours incubation at 37°C.

The tests indicted Biodentine’s antimicrobial activity was superior to that of GIC and MTA, with a mean inhibition zone of 3.2 mm (Table 3). GIC was incapable of inhibiting the growth of Candida. It also indicates that for all three cements, the diameters of the inhibition zones for S. mutans were significantly larger than for E. faecalis, Candida, and E. coli (P < 0.05).

Biodentine shares its characteristics and mode of action with calcium hydroxide. However, Biodentine has better mechanical stability and lower resorption rate

In this study, Biodentine had a significantly more potent antibacterial effect than MTA. The antimicrobial action of MTA is attributed to its high initial pH of 10.2, which rises to 12.5 in 3 hours.

From this study we conclude that:

– All materials showed antimicrobial activity against the tested strains except for GIC on Candida.

– The largest inhibition zone was observed for Streptococcus group.

– Biodentine showed largest inhibition zone.

7.Conclusion

BioDentine, among its many other uses, can be applied as a dentine substitute material in endodontic procedures such as direct and indirect pulp capping. What makes clinicians favor it over MTA is its color stability, its superior mechanical properties such as its compressive and flexural strengths, its shorter setting time, its biocompatibility and bioactivity. Although that does not mean MTA and other root-end fillings are not applicable.

Push Out Bond strength is the strength of the material that allows it to resist dislodgement.

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