|Year : 2019 | Volume
| Issue : 1 | Page : 4-8
Prevention of Tooth Discoloration Due to Calcium-Silicate Cements: A Review
Naghmeh Meraji, Behnam Bolhari, Maryam Rezazadeh Sefideh, Soheil Niavarzi
Department of Endodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
|Date of Web Publication||18-Jun-2019|
Maryam Rezazadeh Sefideh
Department of Endodontics, School of Dentistry, Tehran University of Medical Sciences, North Kargar st., Tehran
Source of Support: None, Conflict of Interest: None
Introduction: Mineral trioxide aggregate (MTA) and other calcium silicate cement similar to that are widely used in endodontic treatments. One of the widely emphasized disadvantages of these cements are the induction of tooth discoloration. The purpose of this study was to investigate the mechanisms of tooth discoloration caused by MTA and MTA-like cements and debate different methods suggested for preventing it. Methods: An electronic search was performed using databases such as Google Scholar, PubMed, PubMed Central, Science Direct, and Scopus by using keywords such as “mineral trioxide aggregate”, “calcium-silicate”, “tooth discoloration”, and “prevention”. Results: Several methods for preventing tooth discoloration caused by MTA and MTA-like cements have been proposed including the application of dentin bonding agents on dentinal walls, use of cements containing radiopacifying agents other than bismuth oxide, and addition of zinc oxide to those cements containing bismuth oxide. Conclusion: Most studies have shown that none of these methods can completely inhibit tooth discoloration but can decrease it to some length.
Keywords: Calcium silicate cement, discoloration, mineral trioxide aggregate, prevention
|How to cite this article:|
Meraji N, Bolhari B, Sefideh MR, Niavarzi S. Prevention of Tooth Discoloration Due to Calcium-Silicate Cements: A Review. Dent Hypotheses 2019;10:4-8
| Introduction|| |
Mineral trioxide aggregate (MTA) is a type of hydrophilic calcium silicate cement first introduced by Torabinejad et al. in 1993 and approved by the Food and Drug Administration to be used in the United States in 1997. It is widely used in endodontics and some of this cement’s applications include root end filling, repair of root perforations, vital pulp therapy, as an apical barrier, and as a coronal barrier. Various in vitro studies have shown this cement to have various advantages and appropriate properties such as good biocompatibility and sealing ability, antibacterial properties, and setting in aqueous environments. Promising clinical outcomes have also been reported for the use of MTA in these clinical applications.,, However, some disadvantages have been reported for this cement including having a long setting time, difficult handling, causing tooth discoloration, and being influenced by environmental conditions.,,,
To overcome these disadvantages, other calcium silicate cements similar to MTA have been introduced over the years [Table 1].
|Table 1 Different types of commercially available calcium-silicate cements available and their composition|
Click here to view
As the use of these cements in clinical cases have increased overtime, many have encountered the tooth discoloration caused by these cements which is usually associated with patient dissatisfaction. This has caused wide emphasis on this subject in such a way that the American Association of Endodontists and the European Society of Endodontology have discussed this matter in the position statement for regenerative endodontic treatment. Considering that the patient’s needs and preferences are one of the three critical important components of an evidence-based approach for clinical treatments, evaluating methods for preventing tooth discoloration in cases requiring the use of calcium silicate cements is of significance. The aim of this review article was to investigate the mechanisms of tooth discoloration caused by calcium silicate cements and discuss different methods suggested for preventing it.
| Methods|| |
An electronic search was performed using databases such as Google Scholar, PubMed, PubMed Central, Science Direct, and Scopus by using keywords such as (“mineral trioxide aggregate” OR “calcium-silicate” OR the name of all calcium silicate cements available) AND (“discoloration” OR “staining potential” OR “color” OR “colour”) AND (“tooth” OR “teeth”) AND/OR “prevention”. The last search was performed on March 2019.
The inclusion criteria were all in vitro, ex vivo, clinical studies, case reports or series, and review articles that evaluated tooth discoloration induced by different calcium silicate-based cements and/or its prevention in peer-reviewed journals published in English. Exclusion criteria included studies published in a language other than English, abstracts from congress.
The articles were selected to address the following research question: How can the discoloration due to calcium silicate-based cements be prevented?
| Result|| |
A total of 427 articles were identified after elimination of duplicates by our search strategy. After evaluation of the titles, abstracts, and full texts, 71 references were included for review and evaluation. Among these articles, nine were review articles regarding discoloration caused by calcium silicate cement, three were clinical trials, and five were case reports/series. Only seven articles were related to tooth discoloration prevention.
| Discussion|| |
Tooth discoloration caused by calcium silicate cements
The first type of MTA introduced was gray MTA. This formulation caused obvious tooth discoloration. As the color of this cement was gray, tooth discoloration was initially considered resultant of its color which was due to the presence of FeO, MgO, and Al2O3 in its composition. Therefore, these metallic oxides were eliminated from its formulation and tooth colored/white MTA (WMTA) was introduced; however, this formulation also caused some degrees of tooth discoloration.,
Overall, reasons for the tooth discoloration caused by WMTA are as follows:
- Presence of 9% iron oxide in WMTA attributed to the calcium aluminoferrite phase of its powder.
- Presence of bismuth oxide as a radiopacifier in its composition, that can interact with strong oxidizing agents, that is, sodium hypochlorite commonly used as an irrigating solution, during endodontic treatments resulting in the production of carbonate bismuth, or interact with collagen in tooth dentin, forming a black precipitate.
- Penetration of erythrocytes from environmental blood into porosities of unset MTA and consequently tooth discoloration due to both discoloration of the MTA bulk and accumulation of hemoglobin or other forms of hematin molecules in dentin.,
Preventing tooth discoloration caused by calcium silicate cements
Based on these mechanisms for causing tooth discoloration, several strategies have been introduced to prevent this discoloration, which are as follows:
- Using calcium silicate cements containing alternative radiopacifying agents such as zirconium oxide and calcium tungstate.,
- Sealing the dentinal tubules of pulp chamber prior to the application of calcium silicate cements using dentin bonding agents.
- Placing MTA below the cementoenamel junction.
- Adding zinc oxide (ZnO) or aluminum fluoride (AlF3) to the powder of WMTA.
Studies have shown that the methods described above cannot completely inhibit tooth discoloration but can decrease it to some extent [Table 2].
|Table 2 Tooth discoloration caused by various calcium-silicate cements in different studies|
Click here to view
In the case of using calcium silicate cements containing alternative radiopacifying agents, studies have shown different outcomes. For instance, most studies reported less tooth discoloration when Biodentine, a calcium silicate cement lacking bismuth oxide and containing zirconium oxide as its radiopacifying agent, was applied.,, However, Ramos et al. showed significantly higher levels of tooth discoloration 12 months after the application of this cement. These levels were similar to the levels reported for WMTA in other studies., BioAggregate is another calcium silicate cement lacking bismuth oxide. This cement contains tantalum peroxide as the radiopacifying agent. Yoldaş et al. have shown that this cement causes lower levels of tooth discoloration compared to ProRoot MTA; however, it caused higher levels of tooth discoloration compared to Biodentine. This was attributed to higher porosity and higher fluid uptake in BioAggregate. Marconyak et al. showed that Endo Sequence Root Repair, a calcium silicate cement containing zirconium oxide and tantalum oxide, and Biodentine did not cause significant tooth discoloration.
Although the use of cements with radiopacifying agents other than bismuth oxide may cause less tooth discoloration, these cement are less radiopaque. Increasing the amount of radiopacifying agents in their formulation causes adverse effects on physical and chemical properties of these cement.
Regarding the use of dentin bonding agents prior to the application of calcium silicate cements, the few available studies performed up to now have shown that this approach can decrease tooth discoloration caused by these cements., The dentin bonding acts as barrier preventing cement accumulation in the access cavity and its contact with dentin collagen. The use of multiple layers of dentin bonding have been suggested for better coverage.
Another approach for preventing tooth discoloration was proposed by Marciano et al., They suggested adding ZnO or AlF3 to white MTA Angelus. They reported that Zn and AlF3 molecules interact with the bismuth oxide, stabilizing it and preventing the interact of bismuth oxide with strong oxidizing agents., They concluded that addition of 5% ZnO to white MTA Angelus inhibited tooth discoloration and increased calcium release from this cement, not affecting its other properties, whereas addition of 5% and 15% AlF3 increased the pH and calcium ion release of the cement. More research is required.
Overall, the majority of articles on this topic of tooth discoloration caused by calcium silicate cements are in vitro or ex vivo studies. These in vitro or ex vivo cannot completely simulate all clinical conditions such as the effect of temperature changes in the oral environment on discoloration and its prevention. Among the few clinical studies including clinical trials and case reports/series, all only reported the occurrence of discoloration and none quantified and compared its intensity. Very few articles have evaluated methods for prevention of tooth discoloration. It seems that although prevention is always better than treatment, this topic requires more attention and research.
| Conclusion|| |
Although strategies have been proposed to prevent tooth discoloration caused by calcium silicate cement, up to now, none were able to completely inhibit it.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993;19:591-595.
Torabinejad M, Parirokh M, Dummer PMH. Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview − part II: other clinical applications and complications. Int Endod J 2018;51:284-317.
Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review − part II: leakage and biocompatibility investigations. J Endod 2010; 36:190-202.
Al-Hezaimi K, Al-Shalan TA, Naghshbandi J, Oglesby S, Simon JH, Rotstein I. Antibacterial effect of two mineral trioxide aggregate (MTA) preparations against Enterococcus faecalis
and Streptococcus sanguis
in vitro. J Endod 2006;32:1053-6.
Ashofteh Yazdi K, Ghabraei S, Bolhari B, Kafili M, Meraji N, Nekoofar MH et al.
Microstructure and chemical analysis of four calcium silicate-based cements in different environmental conditions. Clin Oral Investig 2019;23:43-52.
Mente J, Leo M, Panagidis D, Saure D, Pfefferle T. Treatment outcome of mineral trioxide aggregate: repair of root perforations − long-term results. J Endod 2014;40:790-6.
Parirokh M, Torabinejad M, Dummer P. Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview − part I: vital pulp therapy. Int Endod J 2018;51:177-205.
Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG. Clinical outcomes of artificial root-end barriers with mineral trioxide aggregate in teeth with immature apices. J Endod 2008;34:812-7.
Dammaschke T, Gerth HU, Züchner H, Schäfer E. Chemical and physical surface and bulk material characterization of white ProRoot MTA and two Portland cements. Dent Mater 2005;21:731-8.
Ber BS, Hatton JF, Stewart GP. Chemical modification of ProRoot MTA to improve handling characteristics and decrease setting time. J Endod 2007;33:1231-4.
Kahler B, Rossi-Fedele G. A review of tooth discoloration after regenerative endodontic therapy. J Endod 2016;42:563-9.
Ashofteh Yazdi K, Bolhari B, Sabetmoghaddam T, Meraji N, Kharazifard MJ. Effect of blood exposure on push-out bond strength of four calcium silicate based cements. Iran Endod J 2017;12:196-200.
Bolhari B, Nekoofar MH, Sharifian M, Ghabrai S, Meraji N, Dummer PM. Acid and microhardness of mineral trioxide aggregate and mineral trioxide aggregate-like materials. J Endod 2014;40:432-5.
Sheykhrezae MS, Meraji N, Ghanbari F, Nekoofar MH, Bolhari B, Dummer PMH. Effect of blood contamination on the compressive strength of three calcium silicate-based cements. Aust Endod J 2018;44:255-9.
Galler KM, Krastl G, Simon S, Van Gorp G, Meschi N, Vahedi B et al.
European Society of Endodontology position statement: revitalization procedures. Int Endod J 2016;49:717-23.
Bergenholtz G, Kvist T. Evidencebased endodontics. Endod Topics 2014;31:3-18.
Dettwiler CA, Walter M, Zaugg LK, Lenherr P, Weiger R, Krastl G. In vitro assessment of the tooth staining potential of endodontic materials in a bovine tooth model. Dent Traumatol 2016;32:480-7.
Garcia Lda F, Aguilar FG, Rossetto HL, Sabino MG, Pires-de-Souza Fde C. Staining susceptibility of new calcium aluminate cement (EndoBinder) in teeth: a 1-year in vitro study. Dent Traumatol 2013;29:383-8.
Jang J-H, Kang M, Ahn S, Kim S, Kim W, Kim Y et al.
Tooth discoloration after the use of new pozzolan cement (Endocem) and mineral trioxide aggregate and the effects of internal bleaching. J Endod 2013;39:1598-602.
Mozynska J, Metlerski M, Lipski M, Nowicka A. Tooth discoloration induced by different calcium silicate-based cements: a systematic review of in vitro studies. J Endod 2017;43:1593-601.
Collado-Gonzalez M, Lopez-Garcia S, Garcia-Bernal D, Oñate-Sánchez RE, Tomás-Catalá CJ, Moraleda JM et al.
Biological effects of acid-eroded MTA repair HP and ProRoot MTA on human periodontal ligament stem cells. Clin Oral Investig 2019. doi: 10.1007/s00784-019-02822-2. [Epub ahead of print]
Walsh RM, Woodmansey KF, He J, Svoboda KK, Primus CM, Opperman LA. Histology of NeoMTA Plus and Quick-Set2 in contact with pulp and periradicular tissues in a canine model. J Endod 2018;44:1389-95.
Shokouhinejad N, Nekoofar MH, Pirmoazen S, Shamshiri AR, Dummer PM. Evaluation and comparison of occurrence of tooth discoloration after the application of various calcium silicate-based cements: an ex vivo study. J Endod 2016;42:140-4.
Meraji N, Camilleri J. Bonding over dentin replacement materials. J Endod 2017; 43:1343-9.
Ioannidis K, Mistakidis I, Beltes P, Karagiannis V. Spectrophotometric analysis of coronal discolouration induced by grey and white MTA. Int Endod J 2013;46:137-44.
Arman M, Khalilak Z, Rajabi M, Esnaashari E, Saati K. In vitro spectrophotometry of tooth discoloration induced by tooth-colored mineral trioxide aggregate and calcium-enriched mixture cement. Iran Endod J 2015;10:226-30.
Asgary S, Parirokh M, Eghbal MJ, Stowe S, Brink F. A qualitative X-ray analysis of white and grey mineral trioxide aggregate using compositional imaging. J Mater Sci Mater Med 2006; 17:187-91.
Marciano MA, Duarte MAH, Camilleri J. Dental discoloration caused by bismuth oxide in MTA in the presence of sodium hypochlorite. Clin Oral Investig 2015;19:2201-9.
Camilleri J. Color stability of white mineral trioxide aggregate in contact with hypochlorite solution. J Endod 2014;40:436-40.
Vallés M, Mercadé M, Duran-Sindreu F, Bourdelande JL, Roig M. Influence of light and oxygen on the color stability of five calcium silicate-based materials. J Endod 2013;39:525-8.
Felman D, Parashos P. Coronal tooth discoloration and white mineral trioxide aggregate. J Endod 2013;39:484-7.
Vallés M, Roig M, Duran-Sindreu F, Martínez S, Mercadé M. Color stability of teeth restored with biodentine: a 6-month in vitro study. J Endod 2015;41:1157-60.
Yoldaş SE, Bani M, Atabek D, Bodur H. Comparison of the potential discoloration effect of BioAggregate,Biodentine, and white mineral trioxide aggregate on bovine teeth: in vitro research. J Endod 2016;42:1815-8.
Akbari M, Rouhani A, Samiee S, Jafarzadeh H. Effect of dentin bonding agent on the prevention of tooth discoloration produced by mineral trioxide aggregate. Int J Dent 2012;2012:563203.
Schwendicke F, Stolpe M. Direct pulp capping after a carious exposure versus root canal treatment: a cost-effectiveness analysis. J Endod 2014;40:1764-70.
Marciano MA, Camilleri J, Costa RM, Matsumoto MA, Guimarães BM, Duarte MAH. Zinc oxide inhibits dental discoloration caused by white mineral trioxide aggregate angelus. J Endod 2017;43:1001-7.
Marciano MA, Camilleri J, Lucateli RL, Costa RM, Matsumoto MA, Duarte MAH. Physical, chemical, and biological properties of white MTA with additions of AlF3. Clin Oral Investig 2019;23:33-41.
Marconyak LJ Jr, Kirkpatrick TC, Roberts HW, Roberts MD, Aparicio A, Himel VT et al.
A comparison of coronal tooth discoloration elicited by various endodontic reparative materials. J Endod 2016;42:470-3.
Ramos JC, Palma PJ, Nascimento R, Caramelo F, Messias A, Vinagre A et al.
1-year in vitro evaluation of tooth discoloration induced by 2 calcium silicate-based cements. J Endod 2016;42:1403-7.
Grech L, Mallia B, Camilleri J. Investigation of the physical properties of tricalcium silicate cement-based root-end filling materials. Dent Mater 2013; 29:e20-8.
Khim TP, Sanggar V, Shan TW, Peng KC, Western JS, Dicksit DD. Prevention of coronal discoloration induced by root canal sealer remnants using Dentin Bonding agent: an in vitro study. J Conserv Dent 2018;21:562.
] [Full text]
[Table 1], [Table 2]
|This article has been cited by|
||A critical analysis of research methods and experimental models to study tooth discolouration from endodontic materials
| ||Basil Athanassiadis, Paul V. Abbott, Laurence J. Walsh |
| ||International Endodontic Journal. 2022; |
|[Pubmed] | [DOI]|
||Morphological and Chemical Analysis of Different Types of Calcium Silicate-Based Cements
| ||Okba Mahmoud, Nashwan Abdullah Al-Afifi, Mohideen Salihu Farook, Maysara Adnan Ibrahim, Saaid Al Shehadat, Mohammed Amjed Alsaegh, Sandrine Bittencourt Berger |
| ||International Journal of Dentistry. 2022; 2022: 1 |
|[Pubmed] | [DOI]|
||Evaluation of the properties of Mineral Trioxide Aggregate mixed with Zinc Oxide exposed to different environmental conditions
| ||B. Bolhari,N. Meraji,M. Rezazadeh Sefideh,P. Pedram |
| ||Bioactive Materials. 2020; 5(3): 516 |
|[Pubmed] | [DOI]|