Key words:
Bioceramics - cytotoxicity - root canal sealer - root repair material
INTRODUCTION
Complete filling of root canal systems after chemo-mechanical preparation is critical
to the success of endodontic treatment, as well as to sealing of the root apex[1] since many materials exhibit limited contact with vital tissues in the apical region.
However, in some procedures such as pulp capping/pulpotomy, perforation repair, apexification,
and obturation itself, the materials are placed in proximity to pulp and apical periodontal
tissues.[2] Root repair materials must therefore have excellent characteristics such as biocompatibility
and stability of physical and chemical properties. In addition to these characteristics,
the repair material should stimulate tissue regeneration, especially after endodontic
treatment or apical pathology.[3],[4]
Mineral trioxide aggregate’s (MTA’s) success as a repairing material is undeniable,
although there are some limitations regarding its use. Limitations of MTA include
color alteration, manipulation difficulties, the need of specific instruments, and
delayed setting time. A reduction of the setting period has a beneficial effect on
patient’s relief and on bacterial infection.[5] Based on these limitations, it is necessary to search for new materials that have
better properties.
Bioceramic root canal sealers have recently been introduced into endodontics, with
the same indications of the MTA, that is, or use in obturation and repair procedures.
These cement contain tri- and di-calcium silicate, calcium phosphate, calcium hydroxide,
as well as zirconium oxide as radiopacifier.[6] Bioceramic materials are indicated as an alternative to MTA, due to their excellent
physical, chemical, and biological properties, for example, they have been shown to
induce cell differentiation, to have osteoconductive effects, and to reduce inflammation.[7],[8]
The objective of this systematic review was to evaluate the biocompatibility and interaction
of bioceramic materials with animal and human mesenchymal cells in vitro and in vivo and to compare them with MTA, since there are no randomized clinical trials that
perform this type of comparison. Since it is a relatively new material in the endodontic
market, it is necessary to compare its biocompatibility with materials such as MTA,
which are considered the gold standard of endodontics. The hypothesis tested is that
bioceramic materials are more biocompatible than MTA.
METHODOLOGY
Procedure
This systematic review was conducted according to the guidelines of the PRISMA statement.
The review protocol was registered at PROSPERO (CRD42017056232). The studies were
selected according to the inclusion and exclusion criteria reported below. All abstracts
and full texts were reviewed. None of the manuscript author was contacted during this
process. Disagreements between authors were evaluated and the studies were eliminated
through discussion among researchers until a consensus was reached.
Inclusion and exclusion criteria
The inclusion criteria for this review included studies published in English, without
restrictions on year of publication, and studies which evaluated biocompatibility,
comparing the cytotoxicity of bioceramic materials to MTA. The types of studies were
in vitro and in vivo laboratory studies using animal (no species restriction, either small or large) and
human cells, prospective studies, retrospective studies, and randomized clinical trials.
Excluded were studies that compared the cytotoxicity of bioceramic materials only,
studies that compared bioceramic materials with cement other than MTA, or studies
comparing bioceramic endodontic sealers, since the biocompatibility requirements of
a repairing material are much greater than that of a sealer.
Criteria for selection of the studies
First, studies were selected by analysis of the titles. If the title indicated inclusion,
the abstract was evaluated carefully and articles considered eligible for review (or
in case of doubt) were selected for reading. Disagreements among researchers were
resolved by discussion with a third researcher (MVC). The kappa level of agreement
between authors was 0.81. Due to the lack of randomized clinical trials and prospective
and retrospective studies, this review included in vitro studies using animal and human cells and in vivo animal studies. For this reason, the patient-intervention-comparison-outcome (PICO)
system was adapted: population (studies that evaluated animal and human mesenchymal
cells), intervention (evaluation of the biocompatibility of bioceramic materials),
comparison (MTA), and outcomes (cell viability, changes in cell morphology, inflammatory
responses, cytokine production, and cell adhesion).
Search strategy
Two independent researchers (NGO and PRSA) conducted searches in PubMed/Medline, Web
of Science, and Scopus to identify studies published in English without restriction
on year of publication. The keywords used were “root repair material,” “root canal
sealer,” “cytotoxicity,” and “bioceramics.” The search details were Root repair material
(all fields) AND root canal sealer (all fields) OR (root repair material [all fields]
AND cytotoxicity [All Fields]) OR root repair material (all fields) AND bioceramcis
(all fields) OR root canal sealer (all fields) AND cytotoxicity (all fields) OR root
canal sealer (all fields) AND bioceramics (all fields) OR cytotoxicity (all fields)
AND bioceramics (all fields). This electronic search was complemented by a manual
search conducted from March 1, 2016, to January 8, 2017, in high-impact journals in
endodontics, such as the Journal of Endodontics and International Endodontics Journal.
Assessment of risk of bias
Since no specific evaluation exists for in vitro studies, this review critically evaluated the selected studies using an adapted version
of the CONSORT checklist, which consists of 25 items; however, only 15 items were
used in this study (presence of the first author’s name, type of study being identified
in the title, presentation of a structured abstract, introduction containing a scientific
context, clearly describing the rationale, objectives, and hypothesis tested, methodology
showing study type, cell type, intervention, statistical analysis, evaluation time
between groups studied, if materials were used according to the manufacturers, main
results from each experiment being described, if in the discussion section the results
and their clinical implications were interpreted, whether these results could be translated
into other species or systems, relevance to human biology, and the existence of funding.
If the authors reported the information analyzed, a yes (Y) answer was assigned to
the specific parameter. If the information could not be found, a no (N) answer was
given. Articles reporting 1–5 items were classified as high risk, 6–10 as medium risk,
and 11–15 as low risk of bias. All the 18 presented low risk of bias.
RESULTS
The flowchart of the systematic review is depicted in [Figure 1]. A total of 1486 titles were identified in the initial search. Eighteen studies
were included in this review and processed for data extraction in the following order:
first author, year of publication, type of study (in vitro or in vivo), type of sealer, type of laboratory analysis, type of biocompatibility test, type
of cell used (animal or human), incubation time or experimental period, and the main
results found in each study according to the methodology applied [Table 1].
Figure 1: The flow chart
Table 1:
Data summary of the articles selected
First author
|
Year
|
Type of study
|
Type of Sealer
|
Type of laboratorial analysis
|
Type of biocompatibility test
|
Type of cell
|
Animal or human
|
Experimental period
|
Summary
|
*calcium silicate-based materials MTA: Mineral trioxide aggregate, ERRM: Endosequence
root repair material, PDL: Periodontal ligament, SEM: Scanning electron microscopy,
qRT-PCR: Quantitative reverse-transcriptase-polymerase chain reaction, CCK: Cell counting
kit, ALP: Alkaline phosphatase, NR: Neutral red, CVDE: Crystal violet dye elution,
p-NPP: P-nitrophenyl phosphate, UBP: Ultra-blend Plus, MTT: Colorimetric Test with
Tetrazolium Salt (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide),
DET:Dye exclusion test, MTS: methylthiazol sulfophenyl (3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium,
XTT: 2,3-bis-(2-methoxy-4-nitro-5-sulphenyl)-(2H)-tetrazolium-5-carboxanilide)
|
1. Zhou[9]
|
2013
|
In vitro
|
MTA (Dentsply Tulsa Dental, Tulsa, OK, USA) Glass ionomer (GC Fuji IX GP, Japan) Biodentine*
(Septodont, Saint-Maur-des -Fossés, France)
|
Flow cytometry, SEM
|
Cytotoxicity Odontogenic differentiation
|
Gingival fibroblast
|
Human
|
1, 3 and 7 days
|
Human gingival fibroblastos showed similar response to extracts from Biodentine and
MTA as measured by cytotoxicity assay and cell growth on set materials
|
2. Coaguila -Llerena[10]
|
2016
|
In vitro
|
MTA (Angelus, Londrina, PR, Brazil) ERRM* (Brasseler, Savannah, GA, USA) Super EBA
(Bosworth, Skokie, IL, USA)
|
MTT assay
|
Cytotoxicity
|
PDL
|
Human
|
1, 3 and 7 days
|
MTA and ERRM were less cytotoxic. The behavior of all root end fillings was similar
|
3. Willershausen[11]
|
2013
|
In vitro
|
White MTA (Angelus, Londrina, PR, Brazil) Grey MTA (Angelus, Londrina, PR, Brazil)
ProRoot MTA (Dentsply/Maillefer, Ballaigues, Switzerland) ERRM* (Brasseler, Savannah,
GA, USA)
|
Alamar blue, fluorescence staining
|
Proliferation cellular Cellular growth and morphology
|
Fibroblasts and osteoblasts
|
Human
|
6, 24, 72 and 96 h
|
The root end materials ERRM, ProRoot MTA, and MTA-angelus did not considerably inhibit
the proliferation of PDL fibroblasts and osteoblasts up to 96 h, with ERRM being the
least inhibitory
|
4. Jiang[12]
|
2014
|
In vitro
|
iRoot BP Plus* (Innovative Bioceramix, Vancouver, BC, Canada) iRoot FS* (Innovative
Bioceramix. Vancouver, BC, Canada) ProRoot MTA (Tulsa Dental, Johnson City, TN, USA)
Super-EBA (Bosworth, Skokie, IL, USA)
|
MTT assay, SEM and SEM analysis
|
Cytotoxicity Cellular surface morphology Cell adhesion
|
Osteoblasts (MG63)
|
Human
|
1, 3, 7, and 14 days
|
iRoot FS exhibited the best cell adhesion capacity, and only Super-EBA possessed in vitro cytotoxicity. Given the rapid solidification of iRoot FS, this material showed high
potential for further clinical applications
|
5. Ciasca[13]
|
2012
|
In vitro
|
ProRoot MTA (MTA; Dentsply Tulsa Dental, Johnson City, TN, USA) ERRM* (Brasseler,
Savannah, GA, USA) AH-26 (Dentsply, De Trey, Konstanz, Germany)
|
Photomicrograph images and qRT-PCR
|
Cytotoxicity Cytokine expression
|
Osteoblasts (MG63)
|
Human
|
24, 36 and 48 h
|
ERRM and MTA showed similar cytotoxicity and cytokine expressions
|
6. Chen[2]
|
2016
|
In vitro
|
ERRM* (Brasseler, Savannah, GA, USA) ProRoot MTA (Dentsply Tulsa Dental, Tulsa, OK,
USA)
|
MTT assay and SEM
|
Cell proliferation Cell survival Cellular surface morphology
|
Mesenchymal, PDL, and dental pulp stem cells
|
Human
|
1, 3, 5, and 7 days
|
MTA and ERRM are biocompatible and promote cell proliferation and survival in an ERK-signaling
pathway
|
7. Zhang[14]
|
2013
|
In vitro
|
Bioaggregate* (Innovative Bioceramix, Vancouver, BC, Canada) iRoot BP Plus* (Innovative
Bioceramix, Vancouver, BC, Canada) MTA (Dentsply Tulsa Dental, Tulsa, OK, USA)
|
CCK-8, ALP activity, and qRT-PCR
|
Cell proliferation Cell differentiation Expression of odontoblast differentiation
|
Dental pulp
|
Human
|
1, 3, 5, and 7 days
|
Bioaggregate and iRoot BP Plus were no toxic and able to induce mineralization and
odontoblastic differentiation
|
8. Jovanovic[15]
|
2014
|
In vitro
|
Amalgam (Ekstrakap-D III, ICN Galenika, Serbia) MTA (Angelus, Londrina, PR, Brazil)
Biodentine* (Septodont, Saint Maur-des-Fossés, France)
|
DET, MTT assay, and agar diffusion test
|
Cytotoxicity
|
Fibroblasts (MRC-5 and mouse L929)
|
Human and animal
|
24, 48, and 72 h
|
Biocompatibility tests showed high level of cell compatibility of all the three tested
materials
|
9. Ma[16]
|
2011
|
In vitro
|
ERRM* (Brasseler, Savannah, GA, USA) MTA (Dentsply Tulsa Dental, Tulsa, OK, USA) IRM
(Dentsply Caulk, Milford, DE) Cavit G (3M ESPE AG, Seefeld, Germany)
|
MTT assay and scanning electron microscope
|
Cytotoxicity Cell viability Cell adhesion
|
Fibroblasts
|
Human
|
1, 3 and 7 days
|
ERRM putty and paste displayed similar in vitro biocompatibility to MTA
|
10. Corral Nuñez[17]
|
2014
|
In vitro
|
Biodentine* (Septodont, Saint Maur de Fosses, France) ProRoot MTA (Dentsply Endodontics,
Tulsa, OK)
|
Alamar blue, SEM, and qRT-PCR
|
Cell viability Morphology cellular Cytokine expression
|
Fibroblasts 3T3
|
Animal
|
3, 6, 24 and 72 h
|
Biodentine and MTA showed similar cytotoxicity and induced a similar pattern of cytokine
expression
|
11. Khalil[18]
|
2015
|
In vivo
|
MTA (Dentsply Tulsa Dental, Tulsa, OK) ERRM* (Brasseler, Savannah, GA, USA)
|
Histological evaluation
|
Tissue reactions
|
Subcutaneous
|
Animal (Wistar rats)
|
7 and 30 days
|
Both ERRM and MTA cause an injurious effect when implanted in rat subcutaneous tissues
after 7 and 30 days, ERRM is significantly less injurious to tissues than MTA
|
12. Rifaey[19]
|
2016
|
In vitro
|
ProRoot MTA (Dentsply Tulsa Dental Specialties, Tulsa, OK) ERRM* (Brasseler, Savannah,
GA, USA)
|
qRT-PCR
|
Osteoblast differentiation
|
Osteoblasts
|
Animal
|
7, 14, and 21 days
|
ERRM promotes osteoblast differentiation better than MTA and controls with no material
in three dimensions
|
13. De-Deus[20]
|
2012
|
In vitro
|
iRoot BP Plus* (Innovative Bioceramix, Vancouver, BC, Canada) ProRoot MTA (Dental,
Tulsa, Ok, USA)
|
XTT, NR, and CVDE
|
Cytotoxicity
|
Osteoblast
|
Human
|
24 or 48 h
|
iRoot BP Plus and MTA were biocompatible and did not induce critical cytotoxic effects
|
14. Modareszadeh[21]
|
2012
|
In vitro
|
ERRM* (Brasseler, Savannah, GA, USA) ProRoot MTA (Dentsply Tulsa Dental, Tulsa, OK)
|
MTS and p-NPP assay
|
Cytotoxicity
|
Saos-2 Osteoblast-like
|
Human
|
1, 3 and 7 days
|
Elutes of ERRM significantly reduced the bioactivity and ALP activity of Saos-2 human
osteoblast-like cells. MTA did not affect the cells’ bioactivity or ALP activity
|
15. Damas[22]
|
2011
|
In vitro
|
MTA (Angelus, Londrina, PR, Brazil) ERRM* (Brasseler, Savannah, GA, USA)
|
MTT assay
|
Cytotoxicity
|
Fibroblasts
|
Human
|
24 h
|
The ERRM was shown to have similar cytotoxicity levels to those of ProRoot MTA and
MTA
|
16. Samyuktha[23]
|
2014
|
In vitro
|
MTA (Dentsply Tulsa Dental, Tulsa, OK) ERRM* (Brasseler, Savannah, GA, USA) Biodentine*
(Septodont, Saint Maur de Fosses, France)
|
Trypan blue dye assay
|
Cytotoxicity
|
Fibroblasts
|
Human
|
24 and 48 h
|
MTA was shown to be less toxic to PDL fibroblasts than ERRM and Biodentine
|
17. Hirschman[24]
|
2012
|
In vitro
|
White MTA (Angelus, Londrina, PR, Brazil) ERRM* (Brasseler, Savannah, USA) Dycal (Dentsply
De Tray GmbH, Konstanz, Germany) UBP (Ultradent Products, Inc., South Jordan, UT)
|
MTT assay
|
Cytotoxicity
|
Fibroblasts
|
Human
|
2, 5, and 8 days
|
MTA, ERRM, and UBP had statistically similar adult human dermal fibroblast cytotoxicity
levels. Relative to the negative control, only Dycal was show to have a statistically
significant cytotoxic effect to adult human dermal fibroblasts at all tested
|
18. Lv[25]
|
2017
|
In vitro
|
iRoot FS* (Innovative Bioceramix, Vancouver, BC, Canada) iRoot BP Plus* (Innovative
Bioceramix, Vancouver, BC, Canada) ProRoot MTA (Dentsply Tulsa Dental, Tulsa, OK,
USA)
|
Kit-8, annexin V-FITC and propidium iodide flow, fluorescence microscope and scanning
electron microscope
|
Cell viability Cellular morphology Cell attachment
|
MC3T3-E1
|
Animal
|
24 h, 1, 2 and 3 days
|
iRoot FS and iRoot BP Plus in the set form promoted the viability ofMC3T3-E1 osteoblast
cells. This finding is similar to that observed in MTA
|
As a response to the possible results established in PICO, in general, the bioceramic
materials exhibited similar biological properties when compared to MTA, including
good biocompatibility, cell proliferation and adhesion, low cytotoxicity, low expression
of inflammatory cytokines, and reduced inflammation of human pulp cells.
Eight (44%) of the eighteen studies analyzed used the MTT or MTS assay for laboratory
analysis [Table 1]. Only one study[18] evaluated tissue reactions through histological analysis in subcutaneous tissues
of rats (Wistar rats).
Eleven studies evaluated cytotoxicity, in which, in eight studies, the cytotoxicity
of bioceramic materials was similar to that of MTA.[9],[10],[13],[15],[16],[20],[22],[24] In one study, the results obtained with the bioceramic materials were superior.[12] In contrast, two studies demonstrated greater biocompatibility of the MTA[21],[23] [Table 1].
Two of the studies included in this review evaluated the inflammatory responses and
production and expression of cytokines (interleukin [IL]-1b, tumor necrosis factor-alpha
[TNF-α], IL-6, and IL-8) induced by these materials when in contact with mesenchymal
cells.[13],[17] None of the materials produced a severe inflammatory response [Table 1].
Regarding the evaluation of differentiation of odontoblasts, one study[14] used cell counting kit-8, alkaline phosphatase (ALP) activity, and quantitative
reverse-transcriptase-polymerase chain reaction (qRT-PCR); a second study evaluated
osteoblast differentiation by qRT-PCR;[19] and a third study evaluated the odontogenic differentiation, through flow cytometry
and scanning electron microscopy (SEM).[9]
Regarding cell viability, growth, morphology, and cell adhesion modifications, both
materials obtained similar favorable responses.[2],[11],[12],[16],[17],[25]
DISCUSSION
Few studies have compared the cytocompatibility and cell interactions between bioceramic
materials and MTA and other conventional sealers, such as containing calcium hydroxide,
zinc oxide and eugenol, and resins. Based on the current literature, there are no
systematic reviews that make this kind of comparison.
The cytotoxic potential is one of the most common features investigated in in vitro studies to determine the biocompatibility of root repair materials before testing
them in clinical studies. The cytotoxicity of materials can be due to the presence
of toxic or soluble compounds in their composition. Jiang et al.
[12] compared the cytotoxicity in vitro of iRoot BP Plus, iRoot FS, ProRoot MTA, and Super-EBA in fibroblasts and human osteoblasts.
All materials, with the exception of Super-EBA, exhibited insignificant cytotoxicity.
In addition, iRoot FS demonstrated great potential in other clinical applications
due to its rapid setting time (1 h) and better cell adhesion capacity when compared
to other studied materials.
Rifaey et al.,[19] investigating the gene expression levels of bone sialoprotein, ALP, and Osterix,
found that endosequence root repair material (ERRM) increased the differentiation
of osteoblasts when compared to MTA. The results obtained for the bioceramics can
be explained by the presence of nontoxic compounds in their composition, including
calcium and phosphorus.[12] The biocompatibility of these materials can be attributed to the formation of hydroxyapatite
in the presence of Ca2+ ion during the setting reaction.[26] Another explanation for this result, according to the study, was the use of a not
so frequent biocompatibility test, the three-dimensional culture system (Alvetex scaffold),
which best resembles clinical conditions, where the cells are not placed in contact
with materials. Instead, they are attracted to the proximity of the studied material.[19]
On the other hand, in the study of Modareszadeh et al.,[21] ERRM significantly reduced the bioactivity of human osteoblasts. Samyuktha et al.
[23] found that MTA was less toxic to periodontal ligament fibroblasts than ERRM and
biodentine. The bioactivity of the MTA is dependent on its high pH, which results
in the release of calcium ions after setting.[27] These divergent results may be due to differences in the cell lines (osteoblasts
and fibroblasts), type of laboratory analysis (MTT assay, Trypan blue dye assay),
concentrations and dilutions, and duration of the experiments used to evaluate these
bioceramic materials (ERRM and biodentine).
The contact of cells with the surface of the material is a good indicator that the
materials are biocompatible. In addition, if the materials stimulate cell proliferation
or survival, they are likely to promote the repair process.[28] In many studies, bioceramic materials promoted cell proliferation and viability
and their performance was similar or better than that of MTA. In contrast, De-Deus
et al.[20] found clear differences in cell viability in the XTT assay: tetrazolium dye 2,3-bis-(2-methoxy-4-nitro-5-sulphenyl)-(2H)-tetrazolium-5-carboxanilide
between iRoot BP Plus and ProRoot MTA after 48 h of exposure. The bioceramic material
reduced cell viability significantly more than that observed in the other groups (zinc
oxide- and eugenol-containing cement and control, in which the cells were exposed
to unconditioned medium). However, iRoot BP Plus did not induce critical cytotoxic
effects. Thus, the biocompatibility of the bioceramic sealer was comparable to that
of MTA.
With respect to morphology and the capacity of root canal sealers to promote cell
adhesion, bioceramic materials were also found to be similar or better than MTA. In
the study of Jiang et al.,[12] iRoot FS promoted better cell-cell adhesion (L929 and MG63). Previous studies have
shown that cell adhesion is highly dependent on cell morphology and on the surface
characteristics of the materials.[28],[29] These characteristics influence the behavior, migration, adhesion, and differentiation
of cells.[28]
Chen et al.
[2] found only minimal differences between the surface characteristics of MTA and ERRM
by SEM. Ma et al.[16] still visually confirmed, through the same method, a positive cellular interaction
between the two cement. Both materials promoted cell proliferation and survival. The
similar granular surface characteristics of MTA and ERRM may therefore explain the
similar biological activities of these materials.
On the other hand, Corral Nunez et al.
[17] found changes in cell viability during fibroblast exposure to biodentine and MTA.
After 24 h of exposure to biodentine, the study showed an increase in cell viability,
which was not observed with MTA. This result can be explained by differences in the
composition between the two materials, such as the presence of the radiopacifier.
The radiopacifier for MTA is bismuth oxide. Its use has been questioned for not promoting
cell growth. In addition, calcium phosphate crystals, produced by the reaction of
MTA with the SEM preparation, can generate distorted images. However, over time, it
appears that the cells can repair themselves. Although SEM is the most widely used
method for assessing cell viability in direct contact with calcium silicate-based
materials, studies have shown that sample processing may affect morphology and consequent
cell viability[30] and may contribute to the controversial results.
Regarding inflammatory responses and the production of pro-inflammatory mediators
and cytokines, Ciasca et al.
[13] reported similar effects for ERRM putty, flow, and ProRoot MTA, including the expression
of IL-1b, IL-6, and IL-8 in all samples with minimal expression of TNF-α determined
by RT-PCR. A slight difference was observed between the levels of cytokine expression,
in which the ERRM putty showed higher levels during the first 24 h. One explanation
for this would be based on the use of different types of vehicles applied to create
ERRM flow, although the difference was not significant. Many studies have shown that
the interaction between the components of bioceramics and osteoblasts increases the
production of cytokines, such as ILs and TNF. The high expression of these bone resorption
cytokines has a beneficial effect on bone formation. Thus, these materials present
high repairing potential.
In contrast to most studies that reported similar characteristics for bioceramic materials
and MTA, Khalil and Abunasef[18] showed more tissue injury with MTA than ERRM, after their applications in rat subcutaneous
tissues. The authors observed areas of necrosis and abscesses that were attributed
to the setting of MTA. An exothermic reaction occurs during this process in which
tissues are exposed to high temperatures that can cause ischemia, cell death, and
tissue necrosis.
One of the challenges of this research was the lack of standardization of the biocompatibility
tests and evaluation times used in each study between the bioceramic materials and
MTA. Different methods were likely responsible for the conflicting results. It is
very important that root canal sealers exhibit acceptable biocompatibility and cytotoxicity
and good biological properties. Therefore, the hypothesis tested in this review was
not accepted, since the bioceramic materials showed biological properties similar
to those of MTA such as good biocompatibility indicated by low cytotoxicity as well
as the induction of cell proliferation and adhesion, adequate expression of inflammatory
cytokines, and reduced pulp inflammation after the acute phase.
CONCLUSION
This systematic review therefore suggests that the choice of repair bioceramic materials
or MTA based on biocompatibility should be the professional’s decision.
Financial support and sponsorship
Nil.