Dental Traumatology 2008; 24: 70–73; doi: 10.1111/j.1600-9657.2006.00512.

Calcium ion diffusion from mineral trioxide

aggregate through simulated root resorption
defects

Hüseyin Özgür Özdemir1, Bahar Abstract – The purpose of this study was to investigate the diffusion of calcium
Özçelik1, Bekir Karabucak2, Zafer ions (Ca+2) through exposed dentinal tubules following intracanal application
C. Cehreli3 of mineral trioxide aggregate (MTA). Fifty-two single-rooted teeth were
1
Department of Endodontics, Faculty of instrumented using 2.5% sodium hypochlorite for irrigation between each file
Dentistry, Hacettepe University, Ankara, Turkey; size. Thereafter, standardized defects were created on the root surfaces so as
2
Department of Endodontics, School of Dental to mimic external root resorption. The root canals and external defects received
Medicine, University of Pennsylvania, Phila- a final irrigation of 17% ethylenediaminetetraacetic acid and distilled water.
delphia, PA, USA; 3Department of Pediatric MTA powder was then mixed with saline and placed into the canals. All root
Dentistry, Faculty of Dentistry, Hacettepe surfaces except the cavities were sealed with two coats of varnish. Teeth with
University, Ankara, Turkey
unfilled canals (n = 26) served as controls. The teeth were immersed in saline
after which the release of Ca+2 from the defects into the saline was measured at
1, 3, 7, 14, and 28 days. The results showed diffusion of Ca+2 through the
defects in the dentin in MTA-filled roots with a significant increase in
concentration within time.

Correspondence to: Hüseyin Özgür

Özdemir DDS, Department of Endodontics,
Faculty of Dentistry, Hacettepe University,
Sihhiye 06100, Ankara, Turkey
Tel.: +90 312 305 2260
Fax: +90 312 305 2265
e-mail: [email protected]
Accepted 22 March, 2006

Mineral trioxide aggregate (MTA) has been a biomaterial that calcium (in its ‘hydroxide’ form) is the main
of considerable clinical and laboratory research. Besides chemical compound released by MTA in water. As the
its potential use as a root-end filling material or a root main reason for the use of calcium hydroxide-containing
canal filling material, the use of MTA has been advocated medications is to benefit from the diffusion of Ca+2 and
as a repair material for iatrogenic root perforations and OH) ions through dentinal tubules to the root surface
several other defects caused by caries, resorption, and (14), release of Ca+2 from MTA could yield a desirable
trauma (1–5). Among these, treatment of inflammatory healing effect.
root resorption requires elimination of the inflammatory Mineral trioxide aggregate has also been suggested for
process and inhibition of the activity and formation of use as a root canal filling material (2, 15). Holland et al.
resorbing cells (6, 7). To date, the proposed treatment (4) reported that MTA has the ability to stimulate hard
regimens for internal or external root resorption has been tissue deposition at the apical level after root canal
limited to the use of using calcium hydroxide or other filling. This finding could be extended to other levels of
biomaterials that help promote deposition of a hard the root, with special regard to inflammatory resorption
tissue barrier, while providing a biologic seal (8). where the remaining dentin could serve as a slow-release
A large number of studies have shown that MTA is system of intracanal MTA-derived Ca+2 to the potential
biocompatible, non-toxic, insoluble in the presence of healing site. Consequently, the purpose of this study was
tissue fluids, and is capable of promoting a suitable to determine diffusion of calcium ions through dentinal
environment for the regeneration of periradicular tissues tubules after intracanal MTA application.
(1, 5, 9–11). Moreover, Koh et al. (11) showed that MTA
stimulates the regulation of interleukins which are
Materials and methods
involved in bone turnover. MTA has two specific phases,
comprising calcium oxide and calcium phosphate. Cal- Fifty-two single-rooted human teeth were extracted,
cium oxide reacts with tissue fluids to form calcium cleaned of soft debris and soft tissue remnants, and
hydroxide (1, 10, 12). Fridland and Rosado (13) reported stored in physiologic saline at +4°C for a maximum of

70 Ó 2008 The Authors. Journal compilation Ó 2008 Blackwell Munksgaard

 Calcium diffusion from MTA 71

1 month. The teeth were transferred to room tempera- accordance with the manufacturer’s recommendations,
ture 24 h before experimental procedures. First, the and the mixture was applied to the canal using a low-
crowns were removed at the cementoenamel junction speed lentulo spiral until the material reached the canal
using a low-speed diamond disk under coolant water orifice. The MTA mixture was further condensed with
spray. The root canals were instrumented with K-files to hand pluggers so as to facilitate better adaptation of the
size 60 at the established working lengths and, thereafter, material to root canal walls. Finally, the coronal access
with Gates Glidden burs (nos 3, 4 and 5) at the coronal was sealed with Intermediate Restorative Material
one-third. During cleaning and shaping, irrigation was (IRM). Half of the specimens (n = 26) were left unfilled
made with 5 ml 2.5% sodium hypochlorite (NaOCl) at to serve as controls. The entire root surfaces, except the
each file and bur size. To simulate external root external defects, were then coated with two layers of nail
resorption, standardized defects (3 mm in diameter and varnish. After self-drying of the varnish, each sample was
1 mm in depth) were created using an ISO No. 12 immersed in a separate plastic vial containing 10 ml
cylindrical diamond bur at high speed and water spray, physiologic saline, and transferred to an incubator at
exposing dentin in approximately the middle-third of 37°C and absolute humidity. The Ca+2 concentrations
root surfaces. To determine the remaining dentin thick- and pH values of the immersion media were measured
ness after instrumentation, digital radiographs of the using an AVL 988-4 analyzer with a calcium ion-selective
specimens were obtained with a parallel technique (at electrode (AVL Corp., Graz, Austria) at 1, 3, 7, 14, and
70 kVp and 0.1 s exposure) using a digital radiography 28 days. The results were analyzed statistically by one-
unit (IRIX 70; Trophy, Croissy-Beaubourg, France). way analysis of variance with repeated measures at a
Accordingly, the specimens were placed in a custom- significance level of P = 0.05.
made precision platform mounted on the cone of the
x-ray tube which enabled standardized alignment of the
Results
sensor and the radiographic beam. The digital radio-
graphs were obtained, transferred to a Macintosh G5 The changes in pH and calcium ion release within the
PowerPC, and opened in ImageJ open-source image immersion medium are presented in Tables 1 and 2,
analysis software (V.1.34; National Institutes of Health). respectively. The mean remaining dentin thickness of the
For each specimen, three measurements (coronal, mid- specimens was 1.48 ± 0.13 mm. For all samples, the pH
dle, and apical levels) were made between the base of the values of the immersion media were approximately
cavity and the canal outline (Fig. 1). The reference for between 7.40 and 7.50 and did not demonstrate any
exact calibration of image analysis software was pro- significant change throughout the test period (Fig. 2,
vided by a 2-mm stainless steel orthodontic wire fixed to P > 0.05). Additionally, there was no significant differ-
the platform and radiographed with all teeth. ence between the pH values of the control and experi-
Following radiographic assessments, the root canals mental samples at any evaluation period (Table 1,
and the external defects were irrigated with 17% EDTA P > 0.05).
and 2.5% NaOCl (5 ml each) to remove the smear Initially, (0–3 days), intracanal application of MTA
layer and, thereafter, rinsed with 10 ml unbuffered did not cause a significant shift in the Ca+2 concentra-
isotonic saline. The root canals were dried with paper tion. After day 3, however, a significant increase was
points. observed in the immersion media (Fig. 3, P < 0.05). The
The powder of MTA (Pro-RootTM MTA, Dentsply; control specimens showed a slight initial increase in the
Tulsa Dental, Tulsa, OK, USA) was mixed with saline in
Table 1. Changes in pH within time
MTA Control
Time (days) Mean SEM Mean SEM

1 7.42 0.008 7.41 0.00

3 7.41 0.012 7.38 0.00
7 7.42 0.010 7.37 0.00
14 7.48 0.09 7.41 0.00
28 7.49 0.06 7.47 0.00

Table 2. Release of calcium ions within time (values are

expressed as mg dl)1)
MTA Control
Time (days) Mean SEM Mean SEM

1 0.07 0.06 0.00 0.00

3 0.19 0.02 0.00 0.00
Fig. 1. Typical examples depicting measurement of remaining 7 0.49 0.06 0.17 0.00
dentin thickness. Values for each sample (mm) represent the 14 1.39 0.22 0.21 0.00
mean value of three measurements. The mean remaining dentin 28 3.06 0.31 0.77 0.00
thickness of the specimens was 1.48 ± 0.13 mm.

Ó 2008 The Authors. Journal compilation Ó 2008 Blackwell Munksgaard

72 Özdemir et al.

7.6 root-end filling material, both freshly placed and set

MTA promote dento-alveolar and osseous regeneration
(17). This can be explained in part by the capability of
7.55
MTA MTA to activate cementoblasts to produce matrix
formation by virtue of its better sealing ability, its high
CONTROL
7.5 pH, or by releasing substances that activate cemento-
blasts (1, 3, 18–20). Moreover, MTA preferentially
induces alkaline phosphatase expression and activity in
7.45
both periodontal ligament and gingival fibroblasts (21).
pH

Torabinejad et al. (1) reported that calcium and phos-

7.4 phorus are the main ions in the composition of MTA.
Although Ca+2 may seem to play a lesser role by
activating Ca+2-dependent adenosine triphosphatase in
7.35
the repair potential of surrounding tissues, it is necessary
in cell migration, differentiation, and mineralization (22,
7.3 23). Moreover, in order to stimulate mineralization, the
material should also release calcium, which reacts with
the tissue carbonic gas, forming calcium carbonate which
7.25
1 3 7 14 28 favors mineralization (24). In light of these data, the
present study was conducted to determine the possible
Days
release of calcium ions through dentinal tubules after
Fig. 2. pH changes in the immersion media following applica- intracanal MTA application.
tion of mineral trioxide aggregate (MTA) into root canals (pH In the present study, a significant, time-dependent
values are expressed as mean ± SEM). increase in Ca+2 release was observed from day 3 to day
28. In light of the published data and the Ca+2 release
values obtained herein, it is tempting to speculate that
4 the time-dependent calcium ion release by MTA may
favorably contribute to the repair process, when used
3.5 behind a dentin barrier, such as in root resorptions. In
the present study, the depth of the cavity was set to
3 MTA
1 mm, leaving a considerable amount of sound radicular
Calcium ion release (mg dl–1)

CONTROL dentin that could act as a barrier to the release of MTA.

2.5 Nevertheless, no resorption cavity is standardized in the
real situation. Further studies are required to investigate
2 the effect of remaining dentin thickness on the release of
Ca+2 from MTA.
1.5 One methodological concern is the localization of the
simulated resorption defects. Because the cavity was
1 prepared on the outer mid-root surface, the dentinal
tubules were expected to be oriented at (approximately)
0.5 90° to the base of the defect. This value represents a
mean angulation that may shift to a more oblique angle
0 toward the apical direction. With the remaining dentin
1 3 7 14 28 thickness kept constant, the distance of the tubular
–0.5 Days pathway for the release of ions would relatively increase
as the angulations of the tubules become more oblique.
Fig. 3. Calcium ion release into the immersion media (mg dl)1) Thus, further investigations must also incorporate com-
following application of mineral trioxide aggregate (MTA) into parisons at different levels of the root to draw strict
root canals (values are expressed as mean ± SEM). conclusions. In the present study, MTA did not produce
an alkaline shift in the immersion media. The pH values
Ca+2 concentration (3–7 days) that remained almost were confined to 7.4 (approximate value) during the
stable between day 7 and day 14 and increased to entire test period. This finding can be explained by the
0.77 mg dl)1 at day 28 (Table 2). The Ca+2 concentra- permeability and buffering capacity of dentin, which
tion of the MTA group was significantly greater than may significantly affect the diffusion of hydroxyl ions
that of the control values at all evaluation periods (OH)) through root dentin (23, 25). Therefore, when
(Fig. 3, P < 0.05). used as an indirect orthograde material, MTA should
not be expected to contribute to healing by virtue of its
high pH.
Discussion
The results obtained within the experimental condi-
Mineral trioxide aggregate has demonstrated favorable tions of the present study are suggestive of a potential
treatment outcome when used as a material for repairing use of MTA in the case of inflammatory root resorption.
root perforations at various locations (9, 16). As a However, further studies are required before beneficial

Ó 2008 The Authors. Journal compilation Ó 2008 Blackwell Munksgaard

 Calcium diffusion from MTA 73

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are underway. ide. J Endod 1999;25:161–6.
13. Fridland M, Rosado R. Mineral trioxide aggregate (MTA)
solubility and porosity with different water-to-powder ratios.
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Ó 2008 The Authors. Journal compilation Ó 2008 Blackwell Munksgaard