Pulp exposure resulting from caries, trauma, or tooth preparation can lead to pain and infection, often necessitating extraction or root canal therapy. However, a more conservative approach, direct pulp capping, aims to preserve pulp vitality and avoid extensive treatment. This minimally invasive procedure is employed when a small pulp exposure occurs due to caries, trauma, or during tooth preparation (Zayed et al., 2015). The fundamental principle involves applying a biocompatible material directly over the exposed pulp tissue, forming a protective barrier against bacterial infiltration and noxious stimuli, facilitating natural healing, and promoting reparative dentin formation.

The selection of an appropriate pulp capping material is crucial for the success of the procedure. The material must exhibit biocompatibility, antibacterial activity, the ability to stimulate pulp cell proliferation, and excellent sealing capability (Cardoso et al., 2018). Various materials have been used for pulp capping, including calcium hydroxide, hydrophilic resins, resin-modified glass ionomer cement, mineral trioxide aggregate (MTA), and Biodentine.

MTA is a bioactive, biocompatible material with antibacterial properties and excellent sealing ability, promoting pulp cell proliferation and reparative dentin formation. However, its drawbacks include a long setting time, poor handling properties, and high cost. Despite these limitations, MTA has demonstrated reliability for direct pulp capping, particularly in carious exposures managed with a two-visit treatment protocol (Bogen et al., 2008). In contrast, Biodentine, a newer calcium-silicate-based material, offers advantages such as pulp tissue regeneration, a shorter setting time, and direct application without preconditioning (Nowicka et al., 2013). Studies indicate that inflammation in deep carious lesions may remain reversible, allowing for pulp healing and the preservation of tooth vitality when treated with direct pulp capping (Shaista, 2020).

Comparative studies between MTA and Biodentine have yielded mixed results. Sajid et al. (2016) found MTA to be more effective than calcium hydroxide, while Cuadros-Fernández et al. (2016) reported that both MTA and Biodentine were equally effective in pulpotomies for children. Similarly, Katge and Patil (2017) demonstrated the effectiveness of both materials in permanent first molars. However, Shaista (2020) observed a 91.7% success rate for MTA compared to 83.3% for Biodentine. These findings suggest that while both materials are effective, MTA may offer a slightly higher success rate.

Beyond pulp capping, indirect composite restorations provide advantages for extensive posterior restorations (Silva, 2019). Following endodontic treatment, the absence of nutritive pulp support weakens the dentin protein framework, potentially leading to early bond failure with conventional adhesive techniques (Silva, 2019). Direct composite restorations in large cavities may pose challenges in achieving proper proximal contacts and complete polymerization, which can result in functional and esthetic limitations. Despite these challenges, resin composite materials—especially those incorporating short fibers as fillers—are preferred for direct restorations due to their superior mechanical properties compared to conventional particulate filler composites (Baraba et al., 2021). Conversely, indirect restorations offer improved control over cervical margins, anatomical form, marginal integrity, and occlusion, reducing postoperative sensitivity. Additionally, bioceramic cements provide biocompatibility and bioactivity, facilitating tissue healing and pulp regeneration (Iliescu et al., 2017).

Clinical studies comparing MTA and Biodentine for direct pulp capping highlight the importance of material selection in achieving successful outcomes. Some studies report MTA's superiority over calcium hydroxide (Sajid et al., 2016), while others indicate no significant difference between MTA and Biodentine in pulpotomies for children (Cuadros-Fernández et al., 2016). Additionally, Nowicka et al. (2013) found that both materials elicit favorable histological responses in human pulp, reinforcing their viability for pulp capping procedures. These varying findings underscore the need for further research to determine the optimal material for specific clinical scenarios. Selecting the right biomaterial can prevent the need for costly and invasive root canal treatments, reinforcing the significance of MTA and Biodentine in direct pulp capping procedures.

This study was conducted on patients referring to the Department of Operative Dentistry. Before data collection, ethical approval was obtained from the Institutional Ethical Review Committee (Approval No. ARDC-20-03-17). Informed written consent was acquired from all selected participants using a pre-designed consent form. Teeth meeting the inclusion and exclusion criteria were enrolled in the study and assigned to one of two groups using a consecutive non-probability sampling technique: Group 1 (MTA group) and Group 2 (Biodentine group). All selected teeth were mechanically cleaned and disinfected with a 0.2% chlorhexidine solution. Local anaesthesia (1:100,000 lignocaine hydrochloride with adrenaline) was administered, followed by isolation using a rubber dam. Caries removal, including the excavation of soft carious tissue, was performed using a tungsten carbide fissure bur in a slow-speed handpiece. In cases where accidental pulp exposure occurred during caries excavation, hemostasis was achieved using a cotton pellet moistened with saline. In Group 1, once hemostasis was achieved within 2 to 10 minutes, a 2 mm layer of mineral trioxide aggregate (MTA) was placed over the exposure site, followed by a moist cotton pellet. As MTA requires 24 hours for complete setting, the cavity was temporarily sealed with zinc phosphate cement. In Group 2, after hemostasis was established, the exposed pulp site was capped with Biodentine. The cavity was then sealed temporarily in the same manner using zinc phosphate cement. All patients were recalled for follow-up after three weeks. Subjective pain assessment was conducted using a Visual Analogue Scale (VAS), while pulp vitality was evaluated using an electric pulp test (EPT). The absence of pain and a positive response to EPT were considered indicators of treatment success. During the same visit, all treated teeth were permanently restored with composite resin.

The study included participants aged between 18 and 40 years, with a mean age of 24.69 ± 4.95 years. The sample consisted of 40 individuals, of whom 18 (45.0%) were female and 22 (55.0%) were male. Participants were evenly distributed across the two study groups, ensuring comparability in terms of demographics. In terms of systemic health conditions, cold-drink consumption mellitus was present in 7 participants (17.5%) within the Biodentine group, whereas it was observed in 4 participants (10%) in the MTA group. The presence of cold-drink consumption was considered an important factor in assessing the overall success of direct pulp capping, as systemic conditions can influence wound healing and treatment outcomes. Regarding lifestyle habits, cold-drink consumption was reported among 5 individuals (12.5%) in the Biodentine group and 6 individuals (15%) in the MTA group. Given the known impact of cold-drink consumption on vascular health and tissue healing, its potential role in treatment outcomes was also taken into account. These demographic and health-related characteristics provide essential context for evaluating the effectiveness of MTA and Biodentine in direct pulp capping, as factors such as age, systemic conditions, and cold-drink consumption habits may influence pulp healing and long-term treatment success. (Table 1).

Table 1: Frequency of cold-drink consumption, cold-drink consumption among MTA and Biodentine

The frequency of moderate pain was higher in the MTA group (n = 5, 12.5%) compared to the Biodentine group (n = 2, 5%); however, the difference was not statistically significant (p = 0.49). Similarly, no statistically significant differences were observed between the two groups in terms of the efficacy of pulp capping (p = 0.51) or pulp vitality (p = 0.709) (Table 2).

Table 2: Comparison of pain, efficacy of pulp capping and pulp vitality between Biodentine and MTA

Further comparison of pain intensity, the efficacy of pulp capping, and pulp vitality between Biodentine and MTA across stratified age groups revealed no statistically significant differences for any of the three variables. Likewise, gender-based stratification demonstrated no statistically significant differences in pain, efficacy of pulp capping, or pulp vitality outcomes between the two groups. The differences in pain, pulp capping efficacy, and pulp vitality between the Biodentine and MTA groups were not statistically significant (p > 0.05) (Table 3).

Table 3: Comparison of pain, efficacy of pulp capping and pulp vitality between Biodentine

and MTA stratified by cold-drink consumption

Trioxide Aggregate (MTA) and Biodentine in direct pulp capping (DPC) among patients presenting to Rehman College of Dentistry, Peshawar. The findings revealed no statistically significant differences between Biodentine and MTA in terms of pain, pulp capping efficacy, or pulp vitality. Pulp exposure may result from trauma, mechanical factors, or dental caries. Direct pulp capping is a conservative treatment approach intended to preserve the vitality of the dental pulp and prevent pulpal necrosis (Aguilar & Linsuwanont, 2011). An ideal pulp capping material should sustain pulpal vitality and stimulate the formation of reparative dentin (Qureshi et al., 2014). Both MTA and Biodentine are tricalcium silicate-based cements recognized for their bioactivity and biocompatibility. Their antibacterial properties, high compressive strength, strong adhesion to the tooth structure, and ability to promote reparative dentin formation make them excellent candidates for vital pulp therapy (Camilleri et al., 2013). Although relatively recent additions to restorative dentistry, both MTA and Biodentine have been extensively studied. Katge and Patil (2017) compared their effectiveness in direct pulp capping of permanent first molars in children and reported a 100% success rate for both materials. A more recent study by Shaista (2020) also compared MTA and Biodentine for DPC procedures, reporting an efficacy rate of 91.7% for MTA and 83.3% for Biodentine. Similarly, a study by Abuelniel et al. (2020) assessed the clinical and radiographic outcomes of MTA and Biodentine as pulpotomy agents in traumatized immature anterior permanent teeth with pulp exposure. While no statistically significant differences were noted between the two materials across most clinical parameters, tooth discoloration was significantly more prevalent in the MTA group (p < 0.001). These findings align with the present study, with the exception that the current research excluded traumatized teeth. A randomized controlled trial by Nowicka et al. (2013) demonstrated similar inflammatory responses and dentin bridge formation in human dental pulp when capped with either MTA or Biodentine. However, Biodentine showed a faster setting time, making it a more convenient clinical option. Another study by Koubi et al. (2013) supported this, noting that Biodentine can be applied in a single visit due to its shorter setting time, whereas MTA typically requires a two-visit protocol due to its longer setting duration. In pediatric cases, a systematic review by Mente et al. (2014) compared the success rates of different pulp capping materials and found that MTA had a slightly higher long-term success rate than Biodentine. However, a clinical study by Tran et al. (2022) reported that both materials exhibited similar success rates when used in young permanent teeth, with no significant differences in patient-reported pain scores or pulp survival rates. Recent evidence also suggests that Biodentine may offer superior handling properties and ease of use compared to MTA. A study by Meraji and Camilleri (2017) found that Biodentine demonstrated lower solubility and better sealing ability than MTA, contributing to its effectiveness in maintaining pulp vitality. In contrast, MTA has been associated with tooth discoloration, which can be a concern in esthetically critical areas (Duncan & Kahler, 2017). Recent studies have further explored the efficacy of Mineral Trioxide Aggregate (MTA) and Biodentine in direct pulp capping procedures, providing additional insights into their clinical performance. A randomized clinical trial by Çelik et al. (2019) compared the outcomes of direct pulp capping using calcium hydroxide, MTA, and Biodentine in young permanent teeth with carious exposures. The study found that both MTA and Biodentine exhibited higher success rates compared to calcium hydroxide, with no significant difference between MTA and Biodentine themselves. Similarly, a prospective randomized clinical trial by Awawdeh et al. (2018) assessed the outcomes of vital pulp therapy using MTA and Biodentine. The results demonstrated comparable success rates for both materials, suggesting that Biodentine is as effective as MTA for direct pulp capping. In vitro studies have also contributed to understanding the biological responses elicited by these materials. For instance, a study by Tran et al. (2022) evaluated the histological response of human dental pulp to direct pulp capping with a calcium silicate cement. The findings indicated favorable pulp healing and dentin bridge formation, supporting the use of calcium silicate-based materials like Biodentine and MTA in clinical practice. Furthermore, a retrospective study by Taha and Khazali (2017) investigated the treatment outcomes following direct pulp capping using bioceramic materials in mature permanent teeth with carious exposures. The study reported high success rates for both MTA and Biodentine, reinforcing their effectiveness in maintaining pulp vitality. A narrative review by Camilleri (2023) discussed the evolving role of Biodentine in direct pulp capping, highlighting its bioactive properties and potential advantages over traditional materials. The review emphasized the need for further clinical studies to establish long-term outcomes and optimal clinical protocols. Additionally, a study by Mente et al. (2014) evaluated the outcomes of direct pulp capping using MTA in a prospective study design. The results demonstrated high success rates, further supporting the use of MTA as a reliable pulp capping material. Collectively, these studies reinforce the current understanding that both MTA and Biodentine are effective materials for direct pulp capping with comparable clinical outcomes. While MTA has a longer history of use, Biodentine's favorable handling properties and shorter setting time make it an attractive alternative. However, to determine if one material offers superior long-term benefits over the other, further large-scale, randomized controlled trials with extended follow-up periods are warranted.

Within the limitations of this study, Biodentine and Mineral Trioxide Aggregate (MTA) demonstrated comparable effectiveness in direct pulp capping, with no significant differences in postoperative pain, pulp vitality, or overall success rates. Additionally, patient-related factors such as age, gender, cold-drink consumption, and cold-drink consumption did not significantly influence treatment outcomes, suggesting that both materials are viable options across diverse patient groups. However, long-term clinical studies with larger sample sizes are recommended to further evaluate factors such as dentin bridge formation, treatment longevity, and potential differences in clinical performance. Both materials remain reliable choices for vital pulp therapy, offering predictable and effective preservation of pulp vitality.