Journal of Indian Society of Periodontology
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Year : 2014  |  Volume : 18  |  Issue : 1  |  Page : 5-8  

Can MTA be: Miracle trioxide aggregate?

Department of Periodontology, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Belgaum, Karnataka, India

Date of Web Publication6-Mar-2014

Correspondence Address:
Reshma M Naik
Department of Periodontology, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Near APMC Police Station, Bauxite Road, Belgaum - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-124X.128190

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Mineral trioxide aggregate (MTA) has been used for more than 10 years in the dental community and has often been thought of as a material of choice for the endodontist. The dental pulp is closely related to periodontal tissues through apical foramina, accessory canals, and dentinal tubules. Due to this interrelationship, pulpal diseases may influence periodontal health and periodontal infections may affect pulpal integrity. It is estimated that pulpal and periodontal problems are responsible for more than 50% of tooth mortality. Thus, these associations recommend an interdisciplinary approach. MTA appears to exhibit significant results even in periodontal procedures as it is the first restorative material that consistently allows for over-growth of cementum and may facilitate periodontal tissue regeneration. Thus, in the present review, an attempt is made to discuss the clinical applications of MTA as an interdisciplinary approach.

Keywords: Biocompatibility, cementogenesis, mineral trioxide aggregate, periodontal regeneration

How to cite this article:
Naik RM, Pudakalkatti PS, Hattarki SA. Can MTA be: Miracle trioxide aggregate?. J Indian Soc Periodontol 2014;18:5-8

How to cite this URL:
Naik RM, Pudakalkatti PS, Hattarki SA. Can MTA be: Miracle trioxide aggregate?. J Indian Soc Periodontol [serial online] 2014 [cited 2021 Sep 24];18:5-8. Available from:

   Introduction Top

An ideal endodontic material should seal the pathways of communication between root canal and its surrounding tissues. It should also be nontoxic, noncarcinogenic, biocompatible with the host tissues, insoluble in tissue fluids, and dimensionally stable, and presence of moisture should not affect its sealing ability. Existing restorative materials do not possess these ideal characteristics. [1]

Mineral Trioxide Aggregate (MTA) was developed and has been investigated for various applications since early 1990s. MTA was introduced by Torabinejad and colleagues at Lomalinda University and first described in the dental scientific literature in 1993. It was given approval for endodontic use by the US Food and Drug Administration in 1998. [2]

The development of MTA by Torabinejad was truly a landmark event in dentistry and in endodontics, in particular. The many advantages of MTA expanded its use markedly in different fields of dentistry, of which endodontics is the largest field to take advantage of this material.

   Composition of MTA Top

MTA is a powder consisting of fine hydrophilic particles that set in the presence of moisture. MTA material is a mixture of a refined Portland cement and bismuth oxide. It contains dicalcium silicate, tricalcium silicate, tricalcium aluminate, and tetracalcium aluminoferrite. It is also reported to contain small amounts of other mineral oxides such as SiO 2 , CaO 2 , MgO, K 2 SO 4 , and Na 2 SO 4 , which modify its chemical and physical properties. [3],[4] MTA has a pH of 12.5 after setting, similar to calcium hydroxide or Ca (OH) 2 . [3] This may impart some antimicrobial properties. [5]

Up to 2002, only one MTA material consisting of gray-colored powder was available. Later white mineral trioxide aggregate (WMTA) was introduced as ProRoot MTA, mainly to address esthetic concerns. Studies reported marginal gingival discoloration by gray MTA (GMTA). The major difference between GMTA and WMTA is in the concentrations of Al 2 O 3 , MgO, and FeO. WMTA was found to have 54.9% less Al 2 O 3 , 56.5% less MgO, and 90.8% less FeO. WMTA was also reported to possess an overall smaller particle size than GMTA. It was also suggested that the reduction in magnesium could also contribute to the lighter color of WMTA. [2] Oviir et al. examined the effects of MTA in vitro on the proliferation of oral keratinocytes and cementoblasts. They compared WMTA with GMTA, and their data revealed that cementoblast proliferation significantly increased when grown on the surface of WMTA, compared with cementoblasts grown on GMTA. [6]

   Clinical Applications of MTA Top

At present, MTA is widely used in endodontic therapy. It has been proposed as the material of choice for root-end filling, pulp capping, pulpotomy for primary teeth, apical barrier formation for teeth with necrotic pulps and open apexes, perforation repair, and apexification [Figure 1]. [7]
Figure 1: Clinical applications of MTA

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MTA in periodontics

One of the major problems in aging, periodontal disease, tooth implants, transplantation, or replantation remains the repair of the periodontium and the regeneration of periodontal tissues such as cementum, periodontal ligament, and alveolar bone. Current strategies for periodontal repair and regeneration have been directed at enhancing alveolar bone and periodontal ligament regeneration, and have the limitation that they do not completely restore the architecture of the periodontium. Cementogenesis is a critical event for regeneration of periodontal tissues. However, MTA may appear to exhibit significant results even in periodontal procedures, as it is the first restorative material that consistently allows for over growth of cementum [8],[9] and may facilitate periodontal tissue regeneration. [10] It has been recognized as a bioactive material that is hard tissue conductive, hard tissue inductive, and biocompatible. [1] Correlating to this, evidence regarding cementogenesis and osteogenic capacity of MTA has been amassed. Thomson et al. investigated the effects of MTA on cementoblast. Results of their studies suggest that MTA permits cementoblast attachment and growth and also production of mineralized matrix gene and protein expression. MTA can be considered cementoconductive. [11]

The effects of MTA on survival, mineralization, and expression of mineralization-related genes of cementoblasts were investigated by Sema Hakki et al. Results showed that MTA did not have a negative effect on the viability and morphology of cementoblasts and induced biomineralization of cementoblasts at concentrations of 0.02 and 0.002 mg/ml. Moreover, increased bone sialoprotein (BSP) and collagen type-I mRNA (COL-I mRNA) expression were observed at similar concentrations of MTA. [12] Koh et al. investigated the biological response in human osteoblasts and found increased osteocalcin production when cells were grown on MTA, and also, cells in contact with MTA appeared to have high levels of alkaline phosphatase. [13] Studies by Al-Rabeah et al. showed that human alveolar bone cells interact with MTA. They demonstrated the capacity of MTA to support cell attachment, proliferation, and matrix formation. [14] Various other studies like that of Nascimento et al. evaluated bone repair using MTA, combined with or without calcium hydroxide in the bone defects. Results showed that the MTA used was able to induce bone regeneration and had its action optimized when combined with calcium hydroxide. [15] Pinheiro et al. studied the effects of laser phototherapy (LPT) on bone defects grafted with MTA, bone morphogenetic proteins, and guided bone regeneration (GBR). They concluded that the association of the MTA with LPT and/or not with GBR resulted in a better bone repair. The use of the MTA associated to infrared (IR) LPT resulted in a more advanced and quality bone repair. [16]

Recently, in a systematic review titled "Histological responses of the periodontium to MTA" by Katsamakis et al., it was shown that the results were consistent with regard to MTA's biocompatibility and cementogenic ability. Experimental animal studies show that MTA can promote healing towards regeneration. However, there is a distinct need to examine the clinical performance of MTA in well-controlled prospective human cohort studies. [17]

MTA in combined endo-perio lesions

Various treatment modalities such as the use of guided tissue regeneration alone or in combination with different types of bone grafts, root surface demineralization, enamel matrix derivative, or the application of growth factors have been employed with varying degrees of success in the periodontal regeneration and bone healing process. But considering all the above mentioned beneficial biologic effects of MTA, can MTA enhance this current regeneration scenario? There are various chronic periodontal lesions that may be associated with various tooth-associated defects such as root perforations, furcal perforations, root resorptions, etc., These often pose significant treatment challenges. Therefore, an effective execution of regenerative therapy for periodontal lesion and repair of root surface defects are crucial. Studies by White and Bryant showed that in the treatment of external root resorption and an associated osseous defect, a combined approach utilizing MTA for root surface repair and decalcified freeze-dried bone allograft (DFDBA) and calcium sulphate to address an associated osseous lesion appears to be a viable modality in the treatment of chronic endodontic/periodontal lesions. [18] Baek et al. compared the periapical tissue responses and cementum regeneration in response to three widely used root-end filling materials, amalgam, SuperEBA (super ethoxy benzoic acid), and MTA. MTA showed the most favorable periapical tissue response, with neoformation of cemental coverage over it. [19] Bains et al. obtained favorable clinical results with the use of MTA and platelet-rich fibrin (PRF) in the management of pulpal floor perforation and grade II furcation involvement. [20] Although the overall results in human studies involving MTA materials are very positive, further investigation into the biologic and molecular interactions of MTA with the cells of periodontium is needed. [12]

   Mechanism of Action Top

MTA is a bioactive material and has the ability to create an ideal environment for healing. [7] It can conduct and induct hard tissue formation. [19] From the time that MTA is placed in direct contact with human tissues, it appears that the material does the following:

  • Releases calcium ions and facilitates cell attachment and proliferation
  • Creates antibacterial environment by its alkaline pH
  • Modulates cytokine production
  • Encourages differentiation and migration of hard tissue producing cells
  • Forms hydroxyapatite (or carbonated apatite) on the surface of MTA and provides a biologic seal. [7]

MTA can induce osteoblastic/cementoblastic differentiation of human periodontal ligament cells, which express calcium sensing receptors (CaSR) and bone morphogenetic protein-2 (BMP-2) receptors that are potentially involved in osteogenesis. [21]

The antibacterial and antifungal properties of MTA have been extensively evaluated, and have been attributed to the release of hydroxyl ions, thus creating an antibacterial environment due to high pH. However, the studies present with conflicting reports. An investigation on facultative and strict anaerobic bacteria showed that MTA has an antibacterial effect on some facultative bacteria and has no effect on any species of strict anaerobes. [5] Another investigation reported the antimicrobial activity of MTA-based cements on Micrococcus luteus, Staphylococcus aureus,  Escherichia More Details coli, Pseudomonas aeruginosa, Candida albicans, and Enterococcus faecalis. [22] Conflicting results from antibacterial and antifungal investigations on MTA might be attributed to the various tested species of microorganisms, the source of material prepared, as well as the concentration and the type of MTA used in the studies. [1] Also, the effect of MTA on specific anaerobes is not known. More investigations are required to determine the specific mechanism of action responsible for the bioactivity of MTA.

   Other Advantages of MTA Top

The setting ability of MTA is uninhibited by blood or water. MTA is biocompatible, nonmutagenic, and non-neurotoxic, and does not produce any adverse effects on microcirculation in the connective tissue. [23]

   Drawbacks of MTA Top

The main drawbacks of MTA include a discoloration potential, presence of toxic elements in the material composition, difficult handling characteristics, long setting time, high material cost, an absence of a known solvent for this material, and the difficulty of its removal after curing. [7]

   Conclusion Top

Combined endodontic periodontal lesions represent a real challenge, both for the endodontist and the periodontist. The simultaneous existence of pulpal problems and inflammatory periodontal disease in the same tooth can complicate the treatment of the affected tooth. MTA may be considered beneficial in treatment of such lesions. Reports have strongly suggested that the favorable biologic response exhibited by MTA materials is due to hydroxyapatite formation when these materials are exposed to physiologic solutions. MTA is a promising material with an expanding foundation of research. Owing to applications of MTA in interdisciplinary problems and considering its potential benefits in various disciplines of dentistry like endodontics, pedodontics and periodontics, mineral trioxide aggregate can be appropriately dubbed as miracle trioxide aggregate. However, it should be noted that the supporting data have been overwhelmingly from either in vitro or animal studies. Further longitudinal studies are necessary as at present, insufficient well-designed and controlled clinical studies exist that allow systematic and meta-analysis review of MTA materials in all of its suggested clinical indications.

   References Top

1.Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review - part I: Chemical, physical, and antibacterial properties. J Endod 2010;36:16-27.  Back to cited text no. 1
2.Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in endodontic treatment: A review of literature. Dent Mater 2008;24:149-64.  Back to cited text no. 2
3.Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root-end filling material. J Endod 1995;21:349-53.  Back to cited text no. 3
4.Sarkar NK, Caidedo R, Tirwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod 2005;31:97-100.  Back to cited text no. 4
5.Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Antibacterial effects of some root-end filling materials. J Endod 1995;21:403-6.  Back to cited text no. 5
6.Oviir T, Pagoria D, Ibarra G, Geurtsen W. Effects of gray and white mineral trioxide aggregate on the proliferation of oral keratinocytes and cementoblasts. J Endod 2006;32:21-31.  Back to cited text no. 6
7.Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review- part III: Clinical applications, drawbacks, and mechanism of action. J Endod 2010;36:400-13.  Back to cited text no. 7
8.Torabinejad M, Hong CU, Lee SJ, Monsef M, Pitt Ford TR. Investigation of mineral trioxide aggregate for root-end filling in dogs. J Endod 1995;21:603-8.  Back to cited text no. 8
9.Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR, Miller DA, Kariyawasam SP. Histologic assessment of mineral trioxide aggregate as a root-end filling in monkeys. J Endod 1997;23:225-8.  Back to cited text no. 9
10.Schwartz RS, Mauger M, Clement DJ, Walker WA. Mineral trioxide aggregate: A new material for endodontics. J Am Dent Assoc 1999;130:967-75.  Back to cited text no. 10
11.Thomson TS, Berry JE, Somerman MJ, Kirkwood KL. Cementoblasts maintain expression of osteocalcin in presence of mineral trioxide aggregate. J Endod 2003;29:407-12.  Back to cited text no. 11
12.Hakki S, Bozkurt SB, Hakki EE, Belli S. Effects of mineral trioxide aggregate on cell survival, gene expression associated with mineralized tissues, and biomineralization of cementoblasts. J Endod 2009;35:513-19.  Back to cited text no. 12
13.Koh ET, Torabinejad M, Pitt Ford TR, Brady K, McDonald F. Mineral trioxide aggregate stimulates a biological response in human osteoblasts. J Biomed Res 1997;37:432-9.  Back to cited text no. 13
14.Al-Rabeah E, Perinpanayagam H, MacFarland D. Human alveolar bone cells interact with ProRoot and tooth-colored MTA. J Endod 2006;32:872-5.  Back to cited text no. 14
15.Nascimento C, Issa JP, Iyomasa MM, Regalo SC, Siessere S, Pitol DL, et al. Bone repair using mineral trioxide aggregate combined to a material carrier, associated or not with calcium hydroxide in bone defects. J Micron 2008;39:868-74.  Back to cited text no. 15
16.Pinheiro AL, Aciole GT, Cangussu MC, Pacheco MT, Silveira L Jr. Effects of laser phototherapy on bone defects grafted with mineral trioxide aggregate, bone morphogenetic proteins, and guided bone regeneration: A Raman spectroscopic study. J Biomed Mater Res A 2010;95:1041-7.  Back to cited text no. 16
17.Katsamakis S, Slot DE, Van der Sluis LW, Van der Weijden F. Histological responses of the periodontium to MTA: A systematic review. J Clin Periodontol 2013;40:334-44.  Back to cited text no. 17
18.White C Jr, Bryant N. Combined therapy of MTA and guided tissue regeneration in treatment of external root resorption and an associated osseous defect. J Periodontol 2002;73:1517-21.  Back to cited text no. 18
19.Baek SH, Plenk H Jr, Kim S. Periapical tissue responses and cementum regeneration with amalgam, SuperEBA, and MTA as root-end filling materials. J Endod 2005;31:444-9.  Back to cited text no. 19
20.Bains R, Bains VK, Loomba K, Verma K, Nasir A. Management of pulpal floor perforation and grade II furcation involvement using mineral trioxide aggregate and platelet rich fibrin: A clinical report. Contemp Clin Dent 2012;3:223-7.  Back to cited text no. 20
21.Maeda H, Nakano T, Tomokiyo A, Fujii S, Wada N, Monnouchi S, et al. Mineral trioxide aggregate induces bone morphogenetic protein-2 expression and calcification in human periodontal ligament cells. J Endod 2010;36:647-52.  Back to cited text no. 21
22.Tanomaru-Filho M, Tanomaru JM, Barros DB, Watanabe E, Ito IY. In vitro antimicrobial activity of endodontic sealers, MTA-based cements and Portland cements. J Oral Sci 2007;49:41-5.  Back to cited text no. 22
23.Torabinejad M, Parirokh M. Mineral trioxide aggregate: A comprehensive literature review- Part II: Leakage and Biocompatibility Investigations. J Endod 2010;36:190-202.  Back to cited text no. 23


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