Tooth discoloration induced by apical plugs with hydraulic calcium silicate-based cements in teeth with open apices-a 2-year in vitro study

Clin Oral Investig. 2022 Jan;26(1):375-383. doi: 10.1007/s00784-021-04009-0. Epub 2021 Jun 21.


Objectives: To assess tooth discoloration induced by different hydraulic calcium silicate-based cements (HCSCs), including effects of blood and placement method.

Materials and methods: Eighty bovine teeth cut to a length of 18 mm (crown 8 mm, root 10 mm) were randomly assigned to 10 groups (n = 8), receiving orthograde apical plug treatment (APT). Apical plugs were 4 mm in length and made of ProRoot MTA (Dentsply), Medcem MTA (Medcem), TotalFill BC RRM Fast Set Putty (Brasseler), or Medcem Medical Portland Cement (Medcem) plus bismuth oxide (Bi2O3) with and without bovine blood. Further, orthograde (with or without preoperative adhesive coronal dentin sealing) and retrograde APT were compared. Teeth were obturated with gutta-percha and sealer, sealed with composite and stored in distilled water. Tooth color was measured on apical plug, gutta-percha/sealer, and crown surface before treatment versus 24 h, 1, 3, 6, 12, and 24 months after treatment by spectrophotometry. Color difference (ΔE) values were calculated and analyzed by Shapiro-Wilk test, ANOVA with post hoc tests, Friedman test, t test, and post hoc tests with Bonferroni correction (α = .05).

Results: Tooth discoloration occurred in all groups with no significant differences between HCSCs (p > .05). After 24 months, color changes were prominent on roots but insignificant on crowns. Blood contamination induced a significantly decreased luminescence (p < .05). Blood had a stronger impact on tooth color than Bi2O3. No relevant effects of retrograde placement (p > .05) or preoperative dentin sealing (p > .05) were detected.

Conclusions: Apical plugs of the tested HCSCs cause discoloration of bovine roots, but not discoloration of bovine tooth crowns within a 24-month period.

Clinical relevance: APT should be performed carefully while avoiding direct contact with the coronal dentin, and in that case no aesthetic impairments occur.

Keywords: Blood contamination; Dentin sealing; Mineral trioxide aggregate; Portland cement; Spectrophotometer; Tooth discoloration.

MeSH terms

  • Animals
  • Calcium Compounds / adverse effects
  • Cattle
  • Drug Combinations
  • Root Canal Filling Materials* / adverse effects
  • Silicates / adverse effects
  • Tooth Discoloration* / chemically induced


  • Calcium Compounds
  • Drug Combinations
  • Root Canal Filling Materials
  • Silicates
  • calcium silicate