Serbian Dental Journal, vol.

61, No 2, 2014

ORIGINAL ARTICLE / ORIGINALNI RAD

UDC: 6 ; 616.314.18-085 ; 615.46:616.314-7

DOI: 10.2298/SGS1402065P
DOI:

Direct Pulp Capping Using Biodentine

Marijana Popovi Baji1, Vesna Danilovi1, Branislav Proki2, Bogomir Proki2,
Vukoman Jokanovi3, Slavoljub ivkovi1
Department of Restorative Odontology and Endodontics, School of Dental Medicine, University of Belgrade, Belgrade, Serbia;
Department of Surgery, Faculty of Veterinary Medicine, University of Belgrade, Belgrade, Serbia;
3
Institute of Nuclear Sciences Vina, Belgrade, Serbia
1
2

SUMMARY

Introduction Direct pulp capping is therapeutic method of applying medication on exposed pulp in order to allow
bridge formation and healing process. The aim of this study was to investigate the effect of Biodentine on exposed
dental pulp of Vietnamese pigs.
Material and Methods The study was conducted on 20 teeth of Vietnamese pigs (Sus scrofa domesticus). On buccal
surfaces of incisors, canines and first premolars, class V cavities were prepared and pulp was exposed. In the experimental group (six incisors, two canines and two premolars) the perforation was covered with Biodentine (Septodont,
Saint-Maur-des-Fosses, France). In the control group, the perforation was covered with MTA (Dentsply Tulsa Dental,
Johnson City, TN, USA). All cavities were restored with glass ionomer cement (GC Fuji VIII, GC Corporation, Tokyo,
Japan). Observation period was 28 days. After sacrificing the animals, histological preparations were done to analyze the
presence of dentin bridge, an inflammatory reaction of the pulp, pulp tissue reorganization and the presence of bacteria.
Results Dentin bridge was observed in all teeth (experimental and control groups). Inflammation of the pulp was mild
to moderate in both groups. Neoangiogenesis and many odontoblast like cells responsible for dentin bridge formation
were detected. Necrosis was not observed in any case, neither the presence of Gram-positive bacteria in the pulp.
Conclusion Histological analysis indicated favorable therapeutic effects of Biodentine for direct pulp capping in teeth
of Vietnamese pigs. Findings were similar with Biodentine and MTA.
Keywords: direct pulp capping; Biodentine; MTA; dentin bridge

INTRODUCTION
Direct pulp capping is therapeutic method of placing
a medication on exposed pulp to induce formation of
dentin bridge and healing. Preservation of pulp vitality
is very important process, especially in young patients
and in teeth with complicated multi canal systems [1,
2]. Numerous studies have confirmed calcium hydrox
ide as gold standard for direct pulp capping since its
introduction in dental practice in 1920 [2]. High pH
provides stimulating effect on odontoblasts that initiate
production of tertiary dentin and pulp vitality preser
vation. However, the success rate of calcium hydroxide
as direct pulp capping medicament in published papers
varies from 31% to 100% [3-6]. Due to inadequate bond
of calcium hydroxide with exposed pulp that degrades
over time, porosity of new dentin bridge and appearance
of internal resorption there is need to find more efficient
material [3, 7, 8].
In the past twenty years, great attention was given to
mineral trioxide aggregate ProRoot MTA (Dentsply Tulsa
Dental, Johnson City, TN, USA) for direct pulp capping
and it was shown to induce complete dentin bridge for
mation with no signs of pulp inflammation [9, 10]. MTA
consists of tricalcium silicate, dicalcium silicate, tric

alcium aluminate, calcium sulfate dihydrate, and bismuth

oxide. Numerous studies have confirmed its biocompat
ibility, antimicrobial effect, good sealing ability and good
physical and chemical properties [11, 12]. It is hydrophilic
and therefore can be used in wet operating field and the
presence of blood. It was also confirmed that the thick
ness of dentinal bridge increased after pulp capping using
MTA as compared to calcium hydroxide [13, 14, 15]. MTA
shows excellent properties as material for direct pulp cap
ping and successfully replaces calcium hydroxide because
it does not cause local necrosis of the pulp, while chronic
inflammation of the pulp rarely occurs [15]. MTA causes
functional and cytological changes in pulp cells as well
as their transformation to odontoblast like cells which
produce reparative dentin on the surface of the pulp [16,
17]. However, MTA has inferior antibacterial effect than
calcium hydroxide, it is non stable as powder immediately
after package opening, other disadvantages include high
price on the market and long setting time: setting time
of 10 minutes is specified by the manufacturer, a study
of Torabinejad et al. [18] found setting time between 2
and 4 hours.
Contemporary research aimed to find a material for
direct pulp capping that would have all good properties
of MTA, but also to overcome its shortcomings.

Address for correspondence: Marijana POPOVI BAJI, Department of Restorative Odontology and Endodontics,
School of Dental Medicine, University of Belgrade, Rankeova 4, 11000 Belgrade, Serbia; [email protected]

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Popovi Baji M. et al. Direct Pulp Capping Using Biodentine

Biodentine (Septodont, Saint-Maur-des-Fosses,

France) is a new generation material based on calcium
silicate synthesized by bioactive technology. It is indicated
as filling in all cases of damaged dentin, in the coronal
part of root dentin, but can be also used for direct pulp
capping. It consists of powder (tricalcium silicate, calcium
carbonate and zinc oxide) and liquid (water, calcium
chloride, modified polycarboxylate) and has setting time
of 12 minutes [19]. Biodentine stimulates release of TGF-
from pulpal cells, stimulating reparative dentin formation
in a very short period of time. Using extracted human wis
dom teeth, direct pulp capping using Biodentine showed
good results in healing and pulp regeneration [20]. Ex
perimental study of Tran et al. [21] in rats showed similar
effect of Biodentine and MTA in direct pulp capping in
terms of creating dentin bridge (its thickness, continu
ity, porosity), but significantly inferior performance was
achieved with calcium hydroxide. Recent studies have also
demonstrated favorable therapeutic results of Biodentine
and MTA in direct pulp capping of primary teeth of pigs
[22]. Despite the fact that this new cement has already
been used in dentistry as restorative material, its effect
on the pulp tissue of humans has not yet been demon
strated [22].
The aim of this study was to examine the effect of Bio
dentine in direct pulp capping of exposed pulp in Viet
namese pigs (Sus scrofa domesticus).
MATERIAL AND METHODS
The research was conducted at the Faculty of Veterinary
Medicine, University of Belgrade, with the approval of the
Ethics Committee of the School of Dental Medicine, Uni
versity of Belgrade. The experiment included 20 teeth of
Vietnamese pigs (Sus scrofa domesticus), aged 24 months
and weight about 25 kg. The study procedure complied
with the protocol of the European Good Laboratory Prac
tice (86/609/EEC), which involved the implementation
of main principles of asepsis and antisepsis, conducting
the experiment in the minimum required time without
physical and mental suffering of animals (International
Organization for Standardization, 1997). ProRoot MTA
(Dentsply Tulsa Dental, Johnson City, TN, USA) was used
as control material.
Experimental procedure
All animals were premedicated with atropine at the dose
of 0.03-0.04 mg/kg, and after 15 minutes they were intro
duced to general anesthesia using xylazine in the dose
1.5-2 mg/kg and ketamine 20-25 mg/kg intramuscularly.
After rubber dam placement, the teeth were cleaned with
70% ethanol. On the buccal surfaces of incisors, canines
and first premolars class V cavities were prepared using
round carbide burs and continuous cooling with saline.
Using a small round bur pulp chamber was exposed and
bleeding controlled with sterile cotton pellet. Material was
prepared according to the manufacturers instructions and

applied on the perforation. Teeth in the right quadrants of

upper and lower jaw (6 incisors, two canines and 2 pre
molars) received Biodentine. The same number of teeth
in left quadrants of upper and lower jaw received MTA.
All cavities were restored with glass ionomer cement (GC
Fuji VIII, GC Corporation, Tokyo, Japan). Observational
period was 28 days.
At the end of the procedure, the animals were given
an analgesic dose of butorphanol in the dose of 0.1-0.2
mg/kg. After recovery the animals were kept in individ
ual cages in breeding system. After 4 weeks animals were
sacrificed after introducing general anesthesia and iv ad
ministration of sodium phenobarbital in the dose of 100
mg/kg. The jaws were cut into block sections and tissue
was fixed and prepared for microscopic analysis.
Histological procedure
Tissue for histological analysis was taken from every block
of the experimental sample including the tooth and sur
rounding bone. Samples were collected respecting the
ISO criteria (Technical Report 7405) 28 days after the
exposure of the pulp and direct capping. The material for
histological analysis was fixed in 10% of formalin, decalci
fied in 10% of formic acid (pH=5) and molded in paraffin.
Serial sections were made in mesio-distal direction in the
thickness of 4 m. The samples were stained with hema
toxylin and eosin, by method of Goldner and Gram (for
the microscopic identification of bacteria) and analyzed
using light microscope.
Histological criteria for the evaluation of pulp reaction
were used by the methodology of Shayegan et al. [24].
Formation of dentin bridge (A), morphological reorgan
ization of pulp cells (B), inflammatory reaction of pulp
(C) and presence of bacteria (D) were analyzed using the
following scale:
A) Dentin bridge (thickness, localization, structure,
continuity with surrounding dentin):
0 no dentin bridge
1 incomplete presence of dentin bridge in the area
of exposed pulp
2 presence of lateral dentin bridge
3 presence of dentin bridge which completely en
closes exposed pulp;
B) Morphological reorganization:
0 normal pulp tissue
1 disorganization of odontoblast like cells, odonto
blast hyperactivity and proliferation of blood vessels be
neath the exposed pulp
2 complete disorganization of the pulp tissue
3 pulp necrosis;
C) Inflammatory reaction of the pulp (chronic or acute,
intensity and localization of inflammation) it was mon
itored through the International Organization for Stan
dardization and published criteria of Mjr [25] as:
0 no inflammation or there are few inflammatory
cells in the area of exposure

1 mild inflammation and presence of inflammatory

cells only at the site of exposure

Stomatoloki glasnik Srbije. 2014;61(2):67-74

Table 1. Histological analysis of dental pulp after application of the test materials
Tabela 1. Rezultati histoloke analize stanja zubne pulpe posle primene testiranih materijala
Material
Materijal
Biodentine
MTA

0
0
0

Dentin bridge
Dentinski mosti
1
2
4
3
6
0

3
3
4

Tissue reorganisation
Reorganizacija tkiva
0
1
2
3
1
8
1
0
2
8
0
0

Figure 1. Dentin bridge in the area of perforation covered with Biodentine. Shown in the form of islands of mineralized tissue (green).
Biodentine particles cover the entire surface of the defect (Goldner
Trichrome, 40).
Slika 1. Dentinski mosti u predelu perforacije pulpe prekrivene
biodentinom. Uoava se dentinski mosti u obliku ostrvaca mine
ralizovanog tkiva (zeleno). Iznad dentinskog mostia vide se parti
kule biodentina koje prekrivaju celu povrinu oteenja (Goldner
Trichrome, 40).

2 moderate inflammation with infiltration cells in

the coronal and radicular pulp
3 severe inflammation with cell infiltration which
covers the entire pulp with complete disorganization of
normal pulp tissue;
D) The presence of bacteria:
0 absence of bacteria in the pulp and dentinal tubules
1 bacteria present in dentinal tubules, but not in the
pulp
2 bacteria present along the side walls of pulp chamber
3 bacteria present in the whole pulp, along the side
walls of the pulp chamber and dentinal tubules.
RESULTS
Histological analysis showed that dentin bridge was
formed in all samples of the experimental and control
groups (Table 1). Newly formed dentin had characteris
tics of reparative dentin with or without small number
of irregular dentinal tubules that were in continuity with
surrounding dentin. Complete dentin bridge which closed
pulp perforation was noted in 3 cases with Biodentine
(Figure 1) and 4 cases with MTA (Figure 2). Odontoblast
like cells associated with newly formed dentin were found
below complete dentin bridge. The original odontoblasts
were positioned peripherally. They are identified through
their regular palisade arrangement, eosinophilic cyto
plasm and basal nucleus alignment.

Pulp inflammation
Inflamacija pulpe
0
1
2
3
0
8
2
0
0
7
3
0

Presence of bacteria
Pisustvo bakterija
0
1
2
3
8
2
0
0
7
3
0
0

Figure 2. Complete closure of exposed pulp by newly formed dentin bridge after direct pulp capping using MTA. MTA particles incorporated in dentin bridge can be observed (HE, 40).
Slika 2. Potpuno zatvaranje eksponirane pulpe novostvorenim den
tinskim mostiem nakon prekrivanja sa MTA. Uoavaju se partikule
MTA inkorporirane u dentinski mosti (HE, 40).

Figure 3. Reorganization of the pulp tissue after covering with

Biodentine. Odontoblast like cells that produce dentin bridge are
present (HE, 40).
Slika 3. Reorganizacija pulpnog tkiva nakon prekrivanja biodenti
nom. Uoavaju se elije sline odontoblastima koje stvaraju den
tinski mosti (HE, 40).

Incomplete dentin bridge in the form of dental islets was

observed in 4 teeth in the group of Biodentine and 6 teeth
in the group with MTA. Continuous reparative dentin that
extends along the lateral walls of dentin was recorded in 3
cases in the group of Biodentine while this form of dentin
was not registered in the samples with MTA.
Fully preserved pulp tissue was observed in only one
case in the group of Biodentine and two cases with MTA.
Pulp disorganization characterized by the appearance of
odontoblast like cells and their hyperactivity was observed
in most samples (8 teeth in the experimental and control

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Popovi Baji M. et al. Direct Pulp Capping Using Biodentine

Figure 4. Reparative dentin in the group treated with MTA. Dentin

bridge is separated from surrounding dentin with clearly visible demarcation line. Pulp tissue beneath the dentin bridge has normal
structure (Goldner Trichrome, 100).
Slika 4. Reparativni dentin u grupi uzoraka tretiranih sa MTA. Den
tinski mosti je odvojen od okolnog dentina jasno vidljivom de
markacionom linijom. Pulpno tkivo ispod dentinskog mostia je
normalne strukture (Goldner Trichrome, 100).

Figure 5. In majority of samples in both groups inflammatory cell s

were either absent or present in small numbers (HE, 40).
Slika 5. U veini uzoraka obe grupe nisu uoene elije zapaljenjskog
infiltrata ili je njihov broj bio veoma mali (HE, 40).

Figure 7. Venous stasis in the pulp after covering with Biodentine

and appearance of dilated blood vessels. No bacterial cells in the
pulp (HE, 40).
Slika 7. Venska staza u pulpi zuba posle prekrivanja biodentinom
i dilatirani krvni sudovi, ali bez bakterijskih elija u pulpi (HE, 40).

group), where in the central part of the pulp the presence

of venous stasis, hemorrhage and inflammation was ob
served (Figure 3).
In most of these cases neoangiogenesis with prolif
eration of existing and creation of new blood vessels was
observed indicating healing process and complete revas
cularization. Complete disorganization of the pulp tissue
was registered in the samples of the experimental group,
while it was not seen in samples of the control group (Fig
ure 4). Necrosis was not observed in any case.
Histological analysis after 4 weeks revealed that the fol
lowing experimental pulp capping material in most cases
caused mild to moderate chronic inflammation of pulp tis
sue (Figure 5). Severe inflammation or abscesses were not
observed in any sample. Mild inflammation was present
in 8 samples in the experimental group (Figure 6) and 7
samples in the control group with MTA (Figure 7). Moder
ate inflammation where cellular proliferation was present
both in coronal and radicular pulp was observed in 2 teeth
of the Biodentine group and 3 teeth in the MTA group.
Gram staining showed the absence of gram -positive
bacteria in the pulp of all samples (Figure 7). Small num
ber of bacteria in dentinal tubules was observed in 2 teeth
with Biodentine and 3 teeth with MTA.
DISCUSSION

Figure 6. Dilated blood vessels with signs of venous stasis after pulp
capping with MTA. Inflammatory cells are present (HE, 100).
Slika 6. Dilatirani krvni sudovi sa znacima venske staze posle prekri
vanja pulpe sa MTA. elije zapaljenja ne postoje (HE, 100).

Previous studies with new materials were conducted on

teeth of dogs [17, 26], deciduous and permanent teeth of
pigs [24, 27] as well as monkeys [28]. An important ad
vantage in working with animals is that experiment can
be carried out on large number of teeth in the same time
period and the effect of various materials can be checked
at the same time.
Results of the current study showed similar effects of
Biodentine and MTA. The process of reparative dentino
genesis and complete or partial closure of perforations
with dentin bridge was considered as good therapeutic
result. Dentin bridge was observed in all teeth where

Stomatoloki glasnik Srbije. 2014;61(2):67-74

perforations were capped using Biodentine. Similar re

sults were confirmed by the study of Laurent et al. [20],
where a favorable therapeutic effect of Biodentine was
explained by significant release of TGF-1 in pulp cells
that stimulated odontoblasts to increase their activity and
activate reparative dentinogenesis. Results of the current
study where the pulp was capped by MTA also showed
presence of dentin bridge in all samples which is con
sistent with similar experimental study in pigs done by
Shayegana et al. [24].
In most teeth of both groups, odontoblasts were ob
served just below the dentin bridge with major or minor
structural changes that ranged from mild to complete dis
organization. It is likely that these cells are not true odon
toblasts, but odontoblast like cells (although for definitive
identification additional immunohistochemical analysis is
required). These cells, similarly to true odontoblasts have
elongated shape, palisade orientation and basal nucleus
alignment [29]. They have ability to produce extracellu
lar matrix that after mineralization becomes complete or
incomplete dentin bridge or islands that tend to establish
contact with side dentin walls to close and preserve ex
posed pulp.
In most of the samples in the MTA group reorgan
ization of the tissue below the perforation was observed
(hyperactivity of odontoblast like cells and altered cell
morphology as compared to odontoblasts). This is also
confirmed by the study of Tziafas et al. [17] performed
on dogs. Correlation between the number of odontoblast
like cells, the thickness of the bridge and preservation of
deeper parts of the pulp was found. With increased num
ber of these cells, the thickness of dentin bridge is increas
ing and radicular part of the pulp remains vital [30].
In the group with MTA necrosis was not observed in
any sample. In the experimental study of Tabarsi et al.
[26] in dogs after direct capping with MTA necrosis was
present in 22.7% of samples. Different findings of these
two studies can be explained by the fact that in the study
of Tabarsi et al. MTA was placed after pulpotomy was per
formed whereas in the current study only small exposed
surface of the pulp was covered with MTA.
In the group of Biodentine in most teeth mild inflam
mation was observed, suggesting biocompatibility of the
material [31]. Acute inflammation and necrosis of the pulp
was not observed in any of samples. This can be explained
by good marginal seal achieved with glass ionomer cements
and aseptic conditions as well as good immune status of ex
perimental animals. The results of the current study dem
onstrated the presence of inflammatory cells in the coronal
and radicular part of the pulp. In the control group where
pulp was capped with MTA only few samples showed the
presence of lymphocytes, plasma cells and macrophages,
which is consistent with the findings of other authors [24,
26]. Therapeutic effects were similar in the experimental
and control groups, indicating that Biodentine has favorable
effects on reparative activities of the pulp primarily due to
their physical and chemical properties.
After application of both materials neoangiogenesis was
observed, indicating regenerative processes in the pulp and
successful tissue remodeling. Similar results obtained by

both tested materials can be explained by similar chemical

composition (dicalcium and tricalcium silicate make the
most of the material). On the other hand Murray et al.
suggested that for dentinogenesis the most important is
preservation of pulp and odontoblasts, absence of infection
and necrosis but not the type of material [29].
CONCLUSION
Reparation of pulp exposure was successful in the ex
perimental and control group. In most teeth reparative
dentinogenesis resulted in dentin bridge formation and
preservation of functional and morphological integrity of
the pulp. Histological analysis indicated favorable thera
peutic effects of Biodentine which was similar to MTA
after direct pulp capping of pulp in Vietnamese pigs.
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Received: 15/03/2014 Accepted: 20/05/2014

Serbian Dental Journal, vol. 61, No 2, 2014

Direktno prekrivanje pulpe biodentinom

Marijana Popovi Baji1, Vesna Danilovi1, Branislav Proki2, Bogomir Proki2,
Vukoman Jokanovi3, Slavoljub ivkovi1
Klinika za bolesti zuba, Stomatoloki fakultet, Univerzitet u Beogradu, Beograd, Srbija;
Katedra za hirurgiju, Fakultet veterinarske medicine, Univerzitet u Beogradu, Beograd, Srbija;
3
Institut za nuklearne nauke Vina, Beograd, Srbija
1
2

KRATAK SADRAJ

Uvod Direktno prekrivanje pulpe je terapijski postupak primene leka na eksponiranu pulpu zuba radi zatvaranja pulpne komore i
omoguavanja procesa zarastanja. Cilj ovog rada je bio da se ispita efekat biodentina na eksponiranu pulpu zuba vijetnamske svinje.
Materijal i metode rada Istraivanje je izvreno na 20 zuba vijetnamske svinje (Sus scrofa domesticus). Na vestibularnim povrinama
sekutia, onjaka i prvih premolara uraene su preparacije kaviteta V klase, pri emu je napravljena namerna eksploracija komo
ra pulpe. U eksperimentalnoj grupi (est sekutia, dva onjaka i dva premolara) perforacija je prekrivana preparatom Biodentine
(Septodont, Sent Mor de Fos, Francuska). U kontrolnoj grupi perforacija je prekrivana sa MTA (Dentsply Tulsa Dental, Donson Siti,
Tenesi, SAD). Svi kaviteti su restaurirani glasjonomer-cementom (GC Fuji VIII, GC Corporation, Tokio, Japan). Opservacioni period
trajao je 28 dana. Nakon rtvovanja ivotinja napravljeni su histoloki preparati na kojima su analizirani postojanje dentinskog mo
stia, inflamatorna reakcija pulpe, reorganizacija pulpnog tkiva i prisustvo bakterija.
Rezultati Na svim zubima eksperimentalne i kontrolne grupe zabeleeno je stvaranje dentinskog mostia. Zapaljenje pulpe je bi
lo blago do umereno i u eksperimentalnoj i u kontrolnoj grupi uzoraka. Uoeni su znaci neoangiogeneze i mnotvo elija slinih
odontoblastima koje su odgovorne za stvaranje dentinskog mostia. Nekroza nije zabeleena ni u jednom sluaju, kao ni prisustvo
Gram-pozitivnih bakterija u pulpi.
Zakljuak Histoloka analiza je ukazala na povoljne terapijske efekte biodentina u direktnom prekrivanju pulpe zuba vijetnamskih
svinja. Reakcija pulpe bila je slina onima koje je izazvao MTA.
Kljune rei: direktno prekrivanje pulpe; biodentin; MTA; dentinski mosti

UVOD
Direktno prekrivanje pulpe je terapijski postupak primene leka
na eksponiranu pulpu zuba radi zatvaranja pulpne komore i
omoguavanja procesa zarastanja. Ouvanje vitaliteta pulpe je
izuzetno znaajan postupak, posebno kod karijesnih zuba mla
dih osoba i zuba s komplikovanim viekanalnim sistemima [1,
2]. Brojna istraivanja su potvrdila da je kalcijum-hidroksid tzv.
zlatni standard u direktnom prekrivanju pulpe jo od momenta
njegovog uvoenja u stomatoloku praksu 1920. godine [2]. Za
to su odgovorni visoka pH vrednost ovog preparata i stimula
tivni efekat na odontoblaste koji dovodi do stvaranja tercijarnog
dentina i ouvanja vitaliteta pulpe. Ipak, procenat uspenosti
primene kalcijum-hidroksida u publikovanim radovima je ne
ujednaen od 31% do 100% [3-6]. Zbog neodgovarajue veze
kalcijum-hidroksida sa eksponiranom pulpom, degradacije to
kom vremena, poroznosti novostvorenog dentinskog mostia
i pojave internih resorpcija, postoji potreba za pronalaenjem
efikasnijih materijala [3, 7, 8].
Poslednjih dvadesetak godina velika panja se poklanja mi
neral-trioksid agregatu ProRoot MTA (Dentsply Tulsa Dental,
Donson Siti, Tenesi, SAD), ija je jedna od indikacija i direktno
prekrivanje pulpe, jer dovodi do stvaranja kompletnog dentin
skog mostia i bez znakova inflamacije pulpe [9, 10]. MTA se
sastoji od: trikalcijum-silikata, dikalcijum-silikata, trikalcijumaluminata, kalcijum-sulfata dihidrata i bizmut-oksida. Mnoge
studije su potvrdile njegovu biokompatibilnost, antimikrobni
efekat, dobro zaptivanje i dobre fizike i hemijske osobine [11,
12]. Izuz etno je hidrofilan i zbog toga se moe koristiti i u vla
nom operativnom polju i prisustvu krvi. Potvreno je takoe
da je debljina novostvorenog dentinskog mostia vea posle pre
krivanja pulpe sa MTA nego pri korienju kalcijum-hidroksida
[13, 14, 15]. MTA pokazuje odline osobine kao materijal za
direktno prekrivanje zubne pulpe i uspeno zamenjuje kalci

jum-hidroksid, jer ne prouzrokuje lokalnu nekrozu pulpe, dok

se hronino zapaljenje zubne pulpe ree pojavljuje [15]. MTA
izaziva funkcionalne i citoloke promene u elijama pulpe, kao
i njihovu transformaciju u elije sline odontoblastima, koje
izgrauju fibrodentin, odnosno reparativni dentin na povri
ni eksponirane pulpe [16, 17]. Meutim, MTA ima manji an
tibakterijski efekat od kalcijum-hidroksida, a nedostaci su mu
nestabilnost praha neposredno nakon otvaranja, visoka cena
na tritu i dugo vreme vezivanja: proizvoa navodi vreme
vezivanja od 10 minuta, a studija Torabinedada (Torabinejad)
i saradnika [18] je utvrdila da je vreme vezivanja izmeu dva
i etiri sata.
Cilj aktuelnih istraivanja je pronalaenje materijala za di
rektno prekrivanje pulpe zuba koji bi zadrao sve dobre osobine
MTA, ali i prevaziao njegove mane.
Biodentine (Septodont, Sent Mor de Fos, Francuska) je mate
rijal novije generacije na bazi kalcijum-silikata koji je sintetisan
bioaktivnom tehnologijom. Indikovan je kao ispun u svim slu
ajevima oteenog dentina, kako u kruninom, tako i u koren
skom delu zuba, ali se moe koristiti i za direktno prekrivanje
pulpe. Sastoji se od praha (trikalcijum-silikat, kalcijum-karbo
nat i cink-oksid) i tenosti (voda, kalcijum-hlorid, modifikovani
polikarboksilat) i ima vreme vezivanja od 12 minuta [19]. Bio
dentin stimulie oslobaanje TGF- iz pulpnih elija, to dovodi
do stvaranja reparativnog dentina u vrlo kratkom vremenskom
roku. Na modelu humanih ekstrahovanih treih molara direkt
no prekrivanje pulpe biodentinom pokazalo je dobre rezultate
u zarastanju i regeneraciji pulpe [20]. Eksperimentalna studija
Trana (Tran) i saradnika [21] na pacovima pokazala je slian
efekat MTA i biodentina na regeneraciju pulpe nakon direkt
nog prekrivanja pulpe u pogledu stvaranja dentinskog mostia
(njegove debljine, kontinuiranosti, poroznosti), ali i znatno sla
bije rezultate dejstva kalcijum-hidroksida. Novija istraivanja
su takoe pokazala povoljne terapijske rezultate biodentina i

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MTA kod direktnog prekrivanja pulpe mlenih zuba svinja [22].

Uprkos injenici da se ovaj novi cement ve uveliko koristi u
stomatologiji kao restaurativni materijal, njegov efekat na pulp
no tkivo ljudi jo nije dokazan [22].
Cilj rada je bio da se proveri efekat biodentina na eksponi
ranu pulpu zuba vijetnamskih svinja (Sus scrofa domesticus).
MATERIJAL I METODE RADA
Eksperimentalno istraivanje obavljeno je na Fakultetu veteri
narske medicine Univerziteta u Beogradu uz saglasnost Etikog
komiteta Stomatolokog fakulteta Univerziteta u Beogradu. U
eksperiment je bilo ukljueno 20 zuba vijetnamske svinje (Sus
scrofa domesticus) starosti od 24 meseca i telesne mase od 25 kg.
Tokom rada potovan je protokol Evropske dobre laboratorijske
prakse (86/609/EEC), koji podrazumeva primenu glavnih prin
cipa asepse i antisepse, realizaciju eksperimenta u minimalnom
potrebnom vremenu bez fizikog i duevnog bola ivotinja (Me
unarodna organizacija za standardizaciju, 1997).
Kao kontrolni materijal korien je ProRoot MTA (Dentsply
Tulsa Dental, Donson Siti, Tenesi, SAD), iji su efekti na pulpu
ve poznati.
Eksperimentalni postupak
Kod ivotinje je izvrena premedikacija atropinom u dozi
0,030,04 mg/kg i.m., a nakon 15 minuta ivotinja je uvede
na u optu anesteziju davanjem ksilazina u dozi 1,52 mg/kg
i.m. i ketamina u dozi 2025 mg/kg i.m. Nakon anesteziranja i
postavljanja koferdam-gume radi izolacije, zubi su oieni se
damdesetoprocentnim etanolom. Na vestibularnim povrinama
sekutia, onjaka i prvih premolara okruglim karbidnim bore
rom uraena je preparacija kaviteta V klase uz stalno hlaenje
fiziolokim rastvorom. Potom je malim okruglim borerom eks
ponirana komora pulpe, a krvarenje je kontrolisano sterilnim
kuglicama vate. Zatim je na perforaciju aplikovan prethodno
pripremljen materijal prema uputstvu proizvoaa. Na zubima
desnog kvadranta gornje i donje vilice (ukupno est sekutia,
dva onjaka i dva premolara) primenjen je biodentin.
Na istom broju zuba u levom kvadrantu gornje i donje vilice
postavljen je kontrolni materijal MTA. Svi kaviteti su restaurira
ni glasjonomer-cementom (GC Fuji VIII, GC Corporation, Tokio,
Japan). Opservacioni period trajao je 28 dana.
Posle prestanka dejstva anestezije ivotinji je dat analgetik
butorfanol u dozi 0,10,2 mg/kg, a nakon oporavka svinja je
uvana i gajena u individualnom kavezu u farmskim uslovima.
Posle etiri nedelje ivotinja je rtvovana uvoenjem u optu
anesteziju i davanjem pentobarboton-natrijuma i.v. u dozi od
100 mg/kg. Vilice su iseene na blok sekcije i tkivo je fiksirano
i pripremano za mikroskopsku analizu.
Histoloki postupak
Tkivo za histoloku analizu uzeto je u bloku i svaki uzorak je
sadrao eksperimentalni zub i okolnu kost. Uzorci su prikuplje
ni potujui ISO kriterijume (Technical Report 7405) 28 dana
nakon eksponiranja pulpe i direktnog prekrivanja. Materijal za

histoloku analizu je fiksiran u desetoprocentnom formalinu,

dekalcifikovan u desetoprocentnoj mravljoj kiselini (pH=5) i
kalupljen u parafinu. Na staklenim ploicama su napravljene
serijske sekcije u meziodistalnom smeru debljine 4 m. Pre
parati su bojeni hematoksilin-eozinom metodom po Goldneru
(Goldner) i metodom po Gramu (Gram) zbog mikroskopske
identifikacije bakterija. Materijal je analiziran pod svetlosnim
mikroskopom.
Histoloki kriterijumi za procenu reakcije pulpe su korieni
u skladu s metodologijom ajegana (Shayegan) i saradnika [24].
Analizirani su dentinski mosti (A), morfoloka reorganizaci
ja elija pulpe (B), inflamatorna reakcija pulpe (C) i prisustvo
bakterija (D) prema sledeoj skali:
A) Dentinski mosti (debljina, lokalizacija, struktura, konti
nuitet s okolnim dentinom):
0 nema dentinskog mostia
1 nepotpun dentinski mosti u predelu eksponirane pulpe
2 lateralni dentinski mosti
3 potpuni dentinski mosti koji u celosti zatvara ekspo
niranu pulpu;
B) Morfoloka reorganizacija:
0 normalno pulpno tkivo
1 dezorganizacija elija slinih odontoblastima, hiperak
tivnost odontoblasta i proliferacija krvnih sudova ispod eks
ponirane pulpe
2 potpuna dezorganizacija pulpnog tkiva
3 nekroza pulpe;
C) Inflamatorna reakcija pulpe (hronina ili akutna, inten
zitet i lokalizacija zapaljenja) praena je zahvaljujui Meu
narodnoj organizaciji za standardizaciju (International Organi
zation for Standardization) i objavljenim kriterijumima Mjora
(Mjr) [25] iz 1983. godine:
0 nema zapaljenja ili postoji nekoliko elija zapaljenja u
predelu eksponirane pulpe
1 blago zapaljenje i postojanje elija zapaljenja samo na
mestu eksponirane pulpe
2 umereno zapaljenje gde elijska infiltracija dosee koro
narnu pulpu i deo radiksne pulpe
3 izrazito zapaljenje, gde elijska infiltracija zahvata celu
pulpu s potpunom dezorganizacijom normalnog pulpnog tkiva;
D) Prisustvo bakterija:
0 nema bakterija u pulpi i dentinskim kanaliima
1 bakterije u dentinskim kanaliima, ali ih nema u pulpi
2 bakterije du bonih zidova pulpne komore
3 bakterije u celoj pulpi, du bonih zidova pulpne komore
i u dentinskim kanaliima.
REZULTATI
Rezultati histolokih analiza su pokazali da je dentinski mosti
stvoren kod svih uzoraka i u eksperimentalnoj i u kontrolnoj
grupi (Tabela 1). Novostvoreni dentin imao je odlike reparativ
nog dentina bez nepravilno postavljenih dentinskih kanalia ili
s malim brojem ovakvih kanalia, koji su bili u kontinuitetu s
okolnim dentinom. Kompletan dentinski mosti koji je potpuno
zatvarao pulpni prostor u predelu perforacije zabeleen je u tri
uzorka na kojima je primenjen biodentin (Slika 1) i u etiri kod
kojih je primenjen MTA (Slika 2). Ispod potpunog dentinskog
mostia uoene su elije sline odontoblastima koje su u vezi

Stomatoloki glasnik Srbije. 2014;61(2):67-74

s novonastalim tubularnim dentinom. Originalni odontoblasti

su bili pozicionirani periferno. Oni su prepoznati zahvaljujui
njihovom regularnom palisadnom rasporedu, eozinofilnoj ci
toplazmi i bazalno postavljenim jedrom.
Nep otpun dent inski mosti u vidu dent inskih ostrvac a
uoen je kod etiri zuba u grupi u kojoj je primenjen biodentin
i kod est zuba u grupi gde je primenjen MTA. Kontinuiran
reparativni dentin koji se prostire du lateralnih zidova denti
na uoen je u tri uzorka u grupi zuba kod kojih je primenjen
biodentin, dok takav vid dentina nije zabeleen u uzorcima
kontrolne grupe (MTA).
Potpuno ouvano pulpno tkivo zabeleeno je samo u jednom
uzorku u grupi u kojoj je primenjen biodentin i u dva uzorka na
kojima je primenjen MTA. Dezorganizacija pulpnog tkiva u vidu
pojave elija slinih odontoblastima i njihove hiperaktivnosti
uoena je kod najveeg broja uzoraka (po osam zuba i u eks
perimentalnoj i u kontrolnoj grupi), kod kojih su u centralnom
delu pulpe uoeni venska staza, krvarenje i zapaljenje (Slika 3).
U veini ovih uzoraka uoeni su znaci neoangiogeneze s
proliferacijom postojeih i stvaranjem novih krvnih sudova, to
je ukazivalo na proces zarastanja i potpunu revaskularizaciju.
Potpuna dezorganizacija pulpnog tkiva uoena je u jednom
uzorku eksperimentalne grupe, dok se to nije moglo videti ni
u jednom uzorku kontrolne grupe (Slika 4). Nekroza nije zabe
leena ni u jednom sluaju.
Rezultati histolokih analiza nakon etiri nedelje pokazali su
da je posle prekrivanja pulpe eksperimentalnim materijalom u
najveem broju uzoraka zabeleeno blago ili umereno hronino
zapaljenje (Slika 5). Izrazita upala sa mnotvom elija zapaljenja i
pojava apscesa nisu zabeleeni ni u jednom uzorku. Blago zapalje
nje je ustanovljeno u osam uzoraka eksperimentalne grupe (Slika
6) i u sedam uzoraka grupe sa MTA (Slika 7). Umereno zapaljenje
kod koje elijska infiltracija zahvata koronarnu i deo radiksne
pulpe uoeno je kod dva zuba iz grupe u kojoj je primenjen bio
dentin i kod tri zuba iz grupe gde je prekrivanje vreno sa MTA.
Bojenjem preparata po Gramu uoen je potpuni izostanak
Gram-pozitivnih bakterija u pulpi svih uzoraka (Slika 7). Naj
manji broj bakterija u dentinskim kanaliima zabeleen je kod
dva zuba eksperimentalne grupe, dok su u kontrolnoj grupi
bakterije uoene u tri uzorka.
DISKUSIJA
Dosadanje studije sa novim materijalima vrene su na zubi
ma pasa [17, 26], mlenim i stalnim zubima svinja [24, 27],
odnosno na zubima majmuna [28]. Znaajna prednost u radu
s eksperimentalnim ivotinjama je u tome to se eksperiment
moe realizovati na velikom broju zuba i u istom vremenskom
intervalu moe proveravati efekat razliitih materijala.
Rezultati ove studije su pokazali sline rezultate na zubima u
kontrolnoj i eksperimentalnoj grupi. Proces reparativne denti
nogeneze i potpuno ili delimino zatvaranje perforacione rane
dentinskim mostiem u ovom istraivanju smatrao se dobrim
terapijskim rezultatom.
Kod svih zuba kod kojih je pulpa prekrivena biodentinom
uoen je dentinski mosti. Sline rezultate potvrdila je i studija
Lorena (Laurent) i saradnika [20], gde autori povoljan terapij
ski efekat biodentina objanjavaju znaajnim poveavanjem
oslobaanja TGF-1 iz elija pulpe, koji deluje stimulativno na

odontoblaste i pojaava njihovu sekretornu aktivnost, odno

sno reparativnu dentinogenezu. U kontrolnoj grupi, u kojoj je
direktno na pulpu aplikovan MTA, takoe je uoen dentinski
mosti u svim uzorcima, to je u saglasnosti sa slinom ekspe
rimentalnom studijom na svinjama ajegana i saradnika [24].
U najveem broju zuba obe grupe na mestu eksponirane pul
pe, ispod novostvorenog dentinskog mostia, uoeni su odon
toblasti s manjim ili veim strukturnim promenama koje su
varirale od vrlo blagih do potpune dezorganizacije. Verovatno je
da to zapravo i nisu odontoblasti, ve elije sline odontoblasti
ma (iako su za njihovu konanu identifikaciju potrebne dodat
ne imunohistohemijske analize). One, kao i pravi odontoblasti,
imaju izduen oblik, palisadnu orijentaciju i bazalno postavlje
na jedra [29]. Imaju sposobnost stvaranja i luenja vanelijskog
matriksa, ijom mineralizacijom nastaje reparativni dentin u
vidu potpunog ili nepotpunog dentinskog mostia, odnosno
ostrvaca koja tee da uspostave kontakt sa bonim zidovima
dentina i tako zatvore i sauvaju eksponiranu pulpu.
U najveem broju uzoraka iz grupe MTA primeena je reor
ganizacija tkiva ispod perforacije u vidu hiperaktivnosti elija
slinih odontoblastima i izmenjene morfologije elija u odnosu
na odontoblaste. Ovo potvruju i rezultati studije na psima Cja
fasa (Tziafas) i saradnika [17]. Uoena je i povezanost izmeu
broja elija slinih odontoblastima, debljine mostia i ouvano
sti dubljeg dela tkiva pulpe. S poveanjem broja ovih elija raste
debljina dentinskog mostia, pri emu pulpa u radiksnom delu
zadrava svoj fizioloki izgled [30].
U grupi zuba na kojima je primenjen MTA nekroza nije
uoena ni u jednom uzorku. U eksperimentalnoj studiji na psi
ma Tabarsija (Tabarsi) i saradnika [26], posle direktnog pre
krivanja pulpe, nekroza je uoena u 22,7% uzoraka. Drugaiji
nalazi se mogu objasniti injenicom da je u njihovoj studiji
uraen postupak pulpotomije i postavljen MTA, a nije vreno
direktno prekrivanje male povrine eksponirane pulpe kao u
naoj studiji.
Primenom biodentina kod najveeg broja zuba utvreno je
blago zapaljenje, to govori u prilog biokompatibilnosti mate
rijala [31]. Akutno zapaljenje i nekroza pulpe takoe nisu za
paeni ni u jednom ispitivanom uzorku. To se moe objasniti
dobrim rubnim zatvaranjem kaviteta glasjonomer-cementom
i aseptinim uslovima rada, ali i dobrim imunolokim stanjem
eksperimentalnih ivotinja.
Rezultati nae eksperimentalne studije su otkrili elije zapalje
nja i u koronarnom i u radiksnom delu pulpe. Kod uzoraka kon
trolne grupe, u kojoj je primenjen MTA, u samo nekoliko uzoraka
uoeni su limfociti, plazmociti i makrofagi, to je u saglasnosti s
nalazima drugih autora [24, 26]. Budui da je terapijski efekat bio
vrlo slian u eksperimentalnoj i u kontrolnoj grupi, to ukazuje
na injenicu da i biodentin ima povoljno dejstvo na reparatorne
aktivnosti pulpe zuba vijetnamskih svinja zahvaljujui, pre svega,
svojim fizikim i hemijskim osobinama.
Nakon primene biodentina i MTA dolo je i do neoangio
geneze u pulpi, to ukazuje na regenerativne procese u pulpi i
uspenu remodelaciju tkiva. Slini rezultati dobijeni primenom
ovih materijala mogu se objasniti slinim hemijskim sastavom,
jer oba materijala u najveem procentu sadre dikalcijum i tri
kalcijum-silikat. Naravno, o ovome ima i drugaijih miljenja.
Tako Mari (Murray) i saradnici [29] smatraju da su za zapoinja
nje procesa dentinogeneze najvaniji ouvanost pulpe i odonto
blasta, te nepostojanje infekcije i nekroze, a ne vrsta materijala.

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ZAKLJUAK
Reparacija vetaki izazvanih oteenja zuba eksperimentalnih
ivotinja u eksperimentalnoj i u kontrolnoj grupi bila je vrlo
efikasna. Kod veine zuba proces reparativne dentinogeneze je

ispraen stvaranjem dentinskog mostia i ouvanjem funkci

onalnog i morfolokog integriteta pulpe. Histoloka analiza je
ukazala na povoljne terapijske efekte biodentina u direktnom
prekrivanju pulpe zuba vijetnamskih svinja. Reakcija pulpe bila
je slina onima koje je izazvao MTA.