Clinical success of vital pulp therapy for pulp-exposed permanent teeth: a systematic review and meta-analysis

Natthanon Pusa; Pattama Chailertvanitkul; Suttichai Krisanaprakornkit; Chetta Ngamjarus; Nutthapong Kantrong; Thalerngsak Samaksamarn

doi:10.2334/josnusd.24-0452

Abstract

Purpose: To compare the clinical success of different forms of vital pulp therapy using various pulp-capping materials.

Methods: Two independent researchers selected relevant articles from databases, extracted data, evaluated bias risk, and performed meta-analysis. Among 337 studies retrieved, 21 with a total of 1,816 participants and 1,948 treated permanent teeth were eligible and selected for 17 types of comparison. Meta-analysis was conducted for only six of these 17 comparisons.

Results: Among the six comparisons, the success of direct pulp capping with mineral trioxide aggregate (MTA) was significantly higher than that using calcium hydroxide (relative risk = 1.21, 95% confidence interval = 1.02-1.42, P = 0.03). There was no significant difference in the success of direct pulp capping between mineral trioxide aggregate and biodentine, nor between partial pulpotomy and full pulpotomy for either type of pulp capping material.

Conclusion: The use of MTA for direct pulp capping appears to yield significantly better clinical success than the use of calcium hydroxide.

Introduction

Vital pulp therapy (VPT) was originally recommended only for immature permanent teeth with vital pulp and pulp-exposed teeth with reversible pulpitis [1]. However, with improved understanding of the biology of pulp regeneration together with advances in materials and techniques, VPT can now be applied in selected cases for mature teeth with carious pulp exposure and irreversible pulpitis [2]. The clinical success of VPT depends on the absence of pulp inflammation, a diagnosis of reversible pulpitis, efficient hemostasis, selection of an appropriate pulp-capping material with mild to no toxicity, and use of restorative materials with effective sealing ability [2].

Ideally, VPT should allow the formation of a continuous dentine bridge situated over the exposed pulp, helping to protect the pulp from external stimuli. However, prognostic assessment of VPT is still debatable in view of the various designs of previous studies, including differences in the types of intervention, the types of pulp-capping materials employed, case inclusion criteria, and follow-up periods. Therefore, a systematic review of previous studies together with meta-analysis of pooled data is required to gain an unbiased and accurate prognostic overview of VPT. The first systematic review of VPT for vital permanent teeth with cariously exposed pulp was published in 2011 [1]. Since then, although several similar reviews and meta-analyses have been carried out and disseminated, their findings remain inconclusive for various reasons, including an insufficient number of included studies, high bias within individual studies that would impact the reliability of any systematic review, and an insufficient number of studies involving biodentine, a pulp-capping material that has been introduced clinically for VPT only recently.

Moreover, the scopes of previous systematic reviews and meta-analyses of VPT for permanent teeth have been limited to only specific types of VPT intervention [3], pulp-capping materials [4], permanent teeth with only opened or closed apices, or underlying disease diagnoses [5]. Hence, the number of individual studies included in those reviews was insufficient to justify any conclusions about the overall effectiveness of VPT, or to allow subgroup analysis for testing of additional hypotheses. In addition, several new studies of VPT have been published recently. Accordingly, the objective of the present systematic review was to compare the clinical success rates of VTP using different interventions with various types of pulp-capping materials for vital permanent teeth with pulp exposure as a guide for evidence-based practice.

Materials and Methods

Study inclusion criteria

Type of study

Randomized control trials (RCTs), quasi-RCTs, and clustered RCTs that had compared various types of VPT intervention or various types of pulp-capping material for vital permanent teeth with pulp exposure with a diagnosis of normal pulp, reversible pulpitis, or irreversible pulpitis.

Type of participant

Participants of either sex aged 6 years or more, with permanent tooth pulp exposure due to carious lesions, mechanical insults, or trauma, and radiographic evidence of a normal to widened periodontal ligament space.

Type of intervention

Direct pulp capping, partial pulpotomy, and full pulpotomy with use of calcium hydroxide, mineral trioxide aggregate (MTA), or biodentine as a pulp-capping material.

Type of comparator

Comparisons between different types of VPT interventions or between different types of pulp capping material demonstrating clinical success within a follow-up period of at least 6 months.

Type of outcome

The primary outcome was clinical success of VPT, based on clinical and radiographic findings.

Search methods used for identification of studies

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), SCOPUS, MEDLINE (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Clinical Trials.gov, J-STAGE (JST), Thai Journals Online (ThaiJo), and Grey Literature (OPENGREY.EU) were the electronic databases searched for relevant trials from time of their inception until December 2022. Other additional databases accessible by the authors, including the website of Cochrane Thailand, and references provided in the included studies, were also searched. The keywords used were: “dentition permanent or permanent teeth or permanent tooth”, “dental pulp exposure or pulpal exposure or exposed pulp tissue”, “vital or pulp or therapy or treatment or pulp capping or pulpotomy”, and “clinical trial, randomized or controlled clinical trial or randomized controlled trial or quasi-randomized controlled trial or cluster randomized controlled trial”.

Data collection and management

The results of studies retrieved from the aforementioned databases were saved or manually added in Mendeley Reference Management software version 3.0. (Elsevier Inc., New York, NY, USA). Two of the authors (N.P. and T.S.) independently screened titles and abstracts for records obtained from all electronic and additional databases to decide which studies met the inclusion criteria. Thereafter, full texts of the selected studies were retrieved and uploaded to the Rayyan website (Rayyan, Cambridge, MA, USA) and separately reviewed by these two authors, who independently extracted data from the selected studies. Any disagreements related to study selection or data extraction were resolved by discussion. A third researcher (P.C.) was consulted if any disagreement remained unresolved.

Assessment of the methodological quality of included studies

The risk of bias for the studies included overall was evaluated using seven domains as described in the Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022), including random sequence generation, allocation concealment, blinding of participants, blinding of personnel and outcome assessors, incomplete outcome data, selective reporting bias, and other potential sources of bias. The judgement for each item was “Yes” indicating low risk of bias, “No” indicating high risk of bias, or “Unclear” indicating a lack of information. If the sequence generation and allocation concealment for individual studies were judged to have a low risk of bias, their quality was also assumed to have a low risk of bias.

Data analysis

Data analysis was carried out using RevMan software version 5.4 (Cochrane Collaboration, Oxford, UK). The success rate of VPT in each study, considered to be a categorical variable, was expressed as relative risk (RR) with the 95% confidence interval (CI) in Forest plots. Differences in the success rate between included studies were tested by Cochrane Q. The heterogeneity of results from the included studies was examined by I square (I²). Substantial heterogeneity was determined when I² was ≥50% or P < 0.10. Subgroup analysis was conducted to determine whether there were significant differences between participant age groups, the types of pulp-capping materials used, follow-up periods, or etiologies. If the results showed no substantial heterogeneity (I² < 50), the fixed-effect model was used, while the random-effects model was employed if substantial heterogeneity of the results from included studies was detected but could not be explained by subgroup analysis. Moreover, sensitivity analysis was performed to compare the findings of meta-analysis that included studies with a high risk of bias in two or more of seven domains, as mentioned above. Funnel plotting was conducted to identify any publication bias if at least ten studies were included for each comparison.

Results

A search of eligible original research articles retrieved 321 from various databases, and four were retrieved by citation searching, as shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Fig. 1). Among the 321 records, the titles and abstracts of 251 were screened after removal of 81 duplications using the Mendeley Reference Management and the program of the Rayyan website. Of the 251 studies, 22 were found to meet the inclusion criteria for eligibility; however, one of the 22 studies was excluded because data collection and analysis –separate analyses of clinical and radiographic findings– were not consistent with other included studies. Therefore, data reported in the remaining 21 studies, whose features are listed in Table 1, were extracted and entered into the online RCT form. A total of 1,816 participants with 1,948 treated permanent teeth reported in these 21 studies were compared for their treatment success rates in terms of clinical and radiographic findings. The criteria for clinical success were no pain on palpation or percussion, no tooth discoloration, no tooth mobility, no pocket formation, a positive response to the electrical pulp test, normal gingiva, absence of fistula, and usable for normal mastication [6,7,8,9], while the criteria for radiographic success were absence of any radiolucent lesion in the periapical or furcation area, a normal width of the periodontal ligament space, no apparent internal or external root resorption, or no absence of root dentine growth in terms of either the thickness or length of immature tooth roots [6,7,8,9]. One study reported an insignificant incidence of postoperative pain when MTA or biodentine was used for pulpotomy [10].

Fig. 1 PRISMA flow diagram

Table 1 Characteristics of the 21 included studies

Author (year)	Country	Study design	Sample size (n)	Sample size (t)	Procedure	Pulp capping material	Outcomes
Qudeimat 2007 [21]	Kuwait	RCT	43	64	PP	CH MTA	Success
Kiatwateeratana 2009 [16]	Thailand	RCT	30	30	PP	CH EMD gel	Success Pain
BjØrndal 2010 [9]	Denmark	RCT	58	58	DPC PP	CH	Success
Hilton 2013 [13]	USA	RCT	376	376	DPC	CH MTA	Success
Nosrat 2013 [19]	Iran	RCT	51	51	FP	MTA CEM	Success
Chailertvanitkul 2014 [11]	Thailand	RCT	80	84	PP	CH MTA	Success
Keswani 2014 [15]	India	RCT	62	62	FP	MTA PRF	Success
Brizuela 2017 [10]	Chile	RCT	169	169	DPC	CH MTA Biodentine	Success
Kundzina 2017 [18]	Norway	RCT	70	70	DPC	CH MTA	Success Pain
Taha 2017 [24]	Jordan	RCT	50	50	PP	CH MTA	Success
Asgary 2018 [8]	Iran	RCT	302	302	DPC FP	CEM	Success Pain
Parinyaprom 2018 [20]	Thailand	RCT	59	59	DPC	MTA Biodentine	Success
Suhag 2019 [23]	India	RCT	64	64	DPC	CH MTA	Success
Uesrichai 2019 [25]	Thailand	RCT	69	69	PP	MTA Biodentine	Success
Abuelniel 2020 [6]	Egypt	RCT	33	50	FP	MTA Biodentine	Success
Kumar 2020 [17]	Pakistan	RCT	60	60	FP	MTA Biodentine	Pain
Abuelniel 2021 [7]	Egypt	RCT	30	60	FP	MTA Biodentine	Success
Doranala 2021 [12]	India	RCT	60	60	FP	CH PRF BCs	Success
Uyar 2021 [26]	Turkey	RCT	54	54	PP	CH MTA Biodentine	Success
Ramani 2022 [22]	India	RCT	106	106	PP FP	MTA	Success
Jassal 2023 [14]	India	RCT	50	50	PP FP	Biodentine	Success

Assessment of bias

The risk of bias in each included study is shown in Fig. 2. It was demonstrated that all 21 of the included studies (100%) had low risk of selection bias for random sequence generation, whereas ten (47.62%) had a low risk of selection bias for allocation concealment, whereas the remaining eleven (52.38%) had an unclear risk due to insufficiency of the study details. In contrast, all 21 studies (100%) had a high risk of performance bias for blinding of participants and personnel because it was rather difficult to blind the treatment providers for each intervention as well as each of the pulp-capping materials, which are easily recognizable. Eight of the 21 studies (38.09%) had a low risk of detection bias due to blinding of the outcome assessment for both clinical examination and radiographic interpretation, while eleven (52.38%) and two (9.52%) studies had an unclear risk and a high risk, respectively. Fourteen of the 21 studies (66.67%) had a low risk of attrition bias because outcome data were complete, while one (4.76%) and six (28.57%) had an unclear risk and a high risk, respectively, because the drop-out percentages of follow-up patients exceeded 10%. Seven of the 21 studies (33.33%) had a low risk of reporting bias due to completeness of the reported outcome, as was the case for the registered clinical trials, whereas 13 (61.90%) had an unclear risk because registration of these RCTs was inaccessible and two (9.52%) had a high risk due to incompleteness of the reported outcome. Lastly, 19 of the 21 studies (90.48%) had a low risk of other bias because they had received no financial support from any agency related to pulp- capping materials, while one had an unclear risk or high risk (4.76% each) due to support from a pulp-capping material manufacturer or testing of the authors’ own developed material, respectively.

Fig. 2 Summary of risk of bias in each included study

Comparisons of clinical success and meta-analysis

The results of 16 comparisons of clinical success rates are summarized in Table 2. Meta-analysis was conducted for six of these 16 comparisons because they included two or more studies, while the outcomes of eleven comparisons were derived from a single study [6,11,12,13,14,15,16,17]. Among ten comparisons, no significant difference in the clinical success rate was found either between interventions or between pulp-capping materials in ten comparisons, except for one study [17] showing that biodentine was significantly better than calcium hydroxide as a pulp-capping material for partial pulpotomy (Table 2).

With regard to the effects of different interventions, two studies with a combined number of participants involving 150 treated teeth treated with either biodentine [18] or MTA [19] as a pulp- capping material were included for comparison between partial pulpotomy and full pulpotomy (#3 in Table 2). Meta-analysis using the fixed-effect model revealed no significant difference in success rates between these two interventions (2 studies, I² = 0%, relative risk = 1.09, 95% confidence interval = 0.96-1.23, P = 0.19; Fig. 3).

With regard to the effect of various materials used for direct pulp capping, four studies [8,12,20,21] with different participants and a total of 523 treated teeth were included for comparison between calcium hydroxide and MTA (#4 in Table 2). Due to substantial heterogeneity among these studies (I² = 55), the random-effects model together with subgroup analysis of participant age groups, follow-up periods, and reasons for treatment, was applied. Meta-analysis demonstrated that MTA yielded significantly better clinical success than calcium hydroxide (4 studies, relative risk= 1.21, 95% confidence interval = 1.02-1.42, P = 0.03; Fig. 4A, B, C). However, subgroup analysis of different age groups (P = 0.10; Fig. 4A), different follow-up periods (P = 0.17; Fig. 4B), or different causes (P = 0.51; Fig. 4C) was unable to explain the differences among these studies [8,12,20,21]. Two additional studies [8,22] with different participants and a total of 102 treated teeth were included for meta-analysis of clinical success between MTA and biodentine (#6 in Table 2). The fixed-effect model without subgroup analysis revealed no significant difference in clinical success between MTA and biodentine in this setting (relative risk = 1.09, 95% confidence interval = 0.98-1.22, P = 0.11; Fig. 4D).

To study the effects of different pulp-capping materials for partial pulpotomy, four studies [7,13,23,24] with a total of 193 participants and 216 treated teeth were subjected to meta-analysis of the clinical success rates for calcium hydroxide and MTA (#7 in Table 2). Due to obvious heterogeneity among these studies (I² = 78), the random-effects model together with subgroup analysis of participant age groups and follow-up periods was applied. Subgroup analysis of reasons for treatment was not conducted since all four studies included were appointed for dental caries management. Meta-analysis demonstrated no significant difference between calcium hydroxide and MTA for partial pulpotomy (relative risk = 1.19, 95% confidence interval = 0.95-1.49, P = 0.13; Fig. 5A, B). Subgroup analysis of different age groups (P = 0.06; Fig. 5A) or different follow-up periods (P = 0.31; Fig. 5B) was unable to explain the differences among these studies [7,13,23,24]. Two studies [17,24] with different participants involving 103 treated teeth were subjected to meta-analysis of clinical success for MTA and biodentine (#9 in Table 2). Use of the fixed-effect model without subgroup analysis demonstrated no significant difference in success rates between MTA and biodentine as pulp- capping materials for partial pulpotomy (relative risk = 0.96, 95% confidence interval = 0.85-1.09, P = 0.60; Fig. 5C).

Lastly, to examine the effects of different pulp-capping materials for full pulpotomy, two studies [9,25] with a combined number of 100 treated teeth were subjected to meta-analysis of the clinical success rates for MTA and biodentine (#12 in Table 2). Use of the fixed-effect model without subgroup analysis revealed no significant difference in success rates between MTA and biodentine in this setting (relative risk = 1.00, 95% confidence interval = 0.87-1.16, P = 1.00; Fig. 6).

Table 2 Seventeen comparisons of clinical success rates with six comparisons by meta-analysis

	Comparison	N_s	N_t	I²	Model	RR	95% CI	Subgroup	Interpreted value
1	DPC vs PP	1	51	-	-	-	-	-	ns
2	DPC vs FP	1	114	-	-	-	-	-	ns
3	PP vs FP	2	150	0	fixed-effect	1.09	0.96,1.23	-	ns
4	DPC (CH) vs DPC (MTA)	4	523	55	random-effects	1.21	1.02,1.42	age, time, cause	MTA better than CH (P < 0.05)
5	DPC (CH) vs DPC (Bio)	1	47	-	-	-	-	-	ns
6	DPC (MTA) vs DPC (Bio)	2	102	0	fixed-effect	1.09	0.98,1.22	-	ns
7	PP (CH) vs PP (MTA)	4	216	78	random-effects	1.19	0.95,1.49	age, time	ns
8	PP (CH) vs PP (Bio)	1	36	-	-	-	-	-	Bio better than CH (P < 0.05)
9	PP (MTA) vs PP (Bio)	2	103	0	fixed-effect	0.96	0.85,1.09	-	ns
10	PP (CH) vs PP (EMD)	1	26	-	-	-	-	-	ns
11	FP (MTA) vs FP (Bio)	2	100	0	fixed-effect	1.00	0.87,1.16	-	ns
12	FP (MTA) vs FP (PRF)	1	53	-	-	-	-	-	ns
13	FP (CH) vs FP (BCs)	1	37	-	-	-	-	-	ns
14	FP (CH) vs FP (PRF + BCs)	1	38	-	-	-	-	-	ns
15	FP (BCS) vs FP (PRF + BCs)	1	39	-	-	-	-	-	ns
16	FP (MTA) vs FP (CEM)	1	49	-	-	-	-	-	ns

Fig. 3 Meta-analysis of partial pulpotomy (PP) compared to full pulpotomy (FP)

Risk of bias: A = Random sequence generation (selection bias), B = Allocation concealment (selection bias), C = Blinding of participants and personnel (performance bias), D = Blinding of outcome assessment (detection bias), E = Incomplete outcome data (attrition bias), F = Selective reporting (reporting bias), G = Other bias.

Fig. 4 Meta-analysis of direct pulp capping (DPC) with different capping materials

Meta-analysis of DPC using mineral trioxide aggregate (MTA) compared to that using calcium hydroxide (CH) and subgroup analysis of different age groups (A), various follow-up periods (B), and various reasons for treatment (C) were conducted. Meta-analysis of direct pulp capping using biodentine (Bio) compared to mineral trioxide aggregate (MTA) (D). Risk of bias: A = Random sequence generation (selection bias), B = Allocation concealment (selection bias), C = Blinding of participants and personnel (performance bias), D = Blinding of outcome assessment (detection bias), E = Incomplete outcome data (attrition bias), F = Selective reporting (reporting bias), G = Other bias

Fig. 5 Meta-analysis of partial pulpotomy (PP) using different materials

Meta-analysis of partial pulpotomy (PP) with calcium hydroxide (CH) compared to mineral trioxide aggregate (MTA) and subgroup analysis of different age groups (A), and various follow-up periods (B) were conducted. Meta-analysis of partial pulpotomy with biodentine (Bio) compared to MTA (C). Risk of bias: A = Random sequence generation (selection bias), B = Allocation concealment (selection bias), C = Blinding of participants and personnel (performance bias), D = Blinding of outcome assessment (detection bias), E = Incomplete outcome data (attrition bias), F = Selective reporting (reporting bias), G = Other bias

Fig. 6 Meta-analysis of full pulpotomy (FP) with biodentine (Bio) compared to mineral trioxide aggregate (MTA)

Sensitivity analysis

For comparison between calcium hydroxide and MTA for direct pulp capping (#4 in Table 2), one study [8] was excluded due to a high risk of bias in three of seven domains. Meta-analysis of the remaining three studies [12,20,21] showed that MTA was significantly better than calcium hydroxide as a pulp capping material in this setting (relative risk = 1.29, 95% confidence interval = 1.05-1.58, P = 0.01; Fig. 7A). Moreover, after exclusion of two studies [23,26] that had a high risk of bias in two of seven domains, meta-analysis of the remaining two studies [7,17] (#8 in Table 2) revealed that MTA was not significantly better than calcium hydroxide as a pulp-capping material for partial pulpotomy (relative risk = 1.13, 95% confidence interval = 0.91-1.41, P = 0.27; Fig. 7B). Likewise, after exclusion of one study [24] that had a high risk of bias in two of seven domains, meta-analysis of the remaining one study [17] (#10 in Table 2) showed that biodentine was not significantly better than MTA as a pulp capping material in this setting (relative risk = 1.00, 95% confidence interval = 0.85-1.17, P = 1.00; Fig. 7C).

Fig. 7 Sensitivity analysis of treatment modalities

(A) Sensitivity analysis of direct pulp capping (DPC) with mineral trioxide aggregate (MTA) compared to calcium hydroxide (CH). (B) Sensitivity analysis of partial pulpotomy (PP) with MTA compared to CH. (C) Sensitivity analysis of partial pulpotomy with biodentine (Bio) compared to MTA. Risk of bias: A = Random sequence generation (selection bias), B = Allocation concealment (selection bias), C = Blinding of participants and personnel (performance bias), D = Blinding of outcome assessment (detection bias), E = Incomplete outcome data (attrition bias), F = Selective reporting (reporting bias), G = Other bias

Discussion

Traditionally, calcium hydroxide has been regarded as a gold standard material for vital pulp therapy, allowing comparisons of clinical success rates between various interventions or pulp- capping materials. However, no previous systematic reviews have yet provided sufficiently clear and solid evidence-based data applicable to clinical practice. Accordingly, the inclusion criteria for this study were adjusted to broadly cover a wider range of reports in terms of participant type, the reasons for treatment, such as cariously exposed pulp, mechanical insults, and trauma, and diagnostic criteria indicative of tooth viability, such as normal pulp, reversible pulpitis, and irreversible pulpitis. With regard to outcome, all 23 selected studies had adopted similar criteria for assessment of the success rate in terms of both clinical and radiographic features, consistent with the definition of clinical success specified by the authors, except for pain, where the criteria adopted by a few of the studies were bearable pain [12] or pain relievable with pain killers [15]. Moreover, the inclusion criteria adopted for the present systematic review and meta-analysis in terms of study type were RCT, quasi-RCT, and clustered RCT, which are highly reliable research methodologies. Inclusion of only RCTs in the present study differs from the approach of other previous systematic reviews and meta-analyses of VPT that also included clinical studies without randomization or an appropriate control [1,5].

As far as currently available research data are able to indicate, this systematic review and meta-analysis is the first to have examined the effects of different interventions for partial and full pulpotomy in terms of clinical success rate. Two of the included studies [18,19] using calcium silicate – either biodentine or MTA – as a pulp-capping material for cariously exposed pulp of mature permanent teeth with irreversible pulpitis, both with a follow-up period of 1 year. No significant difference in the success rate between these two interventions was evident.

The present meta-analysis of four studies [8,14,20,21] that had compared direct pulp capping with calcium hydroxide and with MTA demonstrated that MTA yielded significantly better results. This is consistent with the systematic review by Aguilar and Linsuwanont [1] that made an indirect comparison and the systematic review and meta-analysis by Cushley et al. [5]. MTA may outperform calcium hydroxide for direct pulp capping because pulpal responses to these two materials may differ. Calcium hydroxide has a high pH, helping to reduce the acidity of inflammation, but irritates pulp cells, causing necrotic coagulum during the first four hours after contact, and then induces odontoblast-like differentiation to form a dentine bridge beneath the necrotic tissue. In contrast, MTA does not cause pulp necrosis because it has lower cytotoxicity and is more biocompatible with pulp tissues and stem cells than calcium hydroxide [27].

The present meta-analysis of four studies [7,17,23,25] that had compared pulp capping with calcium hydroxide and with MTA for partial pulpotomy revealed no significant difference in clinical success, consistent with the systematic review by Aguilar and Linsuwanont [1] and the systematic review and meta-analysis by Chen et al. [4], involving immature permanent teeth with follow-up periods of 6 and 12 months. One explanation for this absence of any significant difference may be that partial pulpotomy is considered a highly effective intervention for VPT, as inflamed pulp is removed effectively to a depth of 2-4 mm [7,17,23,25]. This depth of removal would be enough to eradicate any remnant inflamed pulp, and such inflammation is known to extend as deeply as 2 mm after 1 week of pulp exposure. Moreover, in two of the above studies [7,23], partial pulpotomy was performed under a diagnosis of reversible pulpitis, and a comparable clinical success rate exceeding 90% was achieved in both the calcium hydroxide and MTA groups, whereas in the latter two studies [17,25] partial pulpotomy was conducted for irreversible pulpitis, resulting in a lower success rate for calcium hydroxide than for MTA. However, because of the smaller sample size of the latter two studies [17,25], meta-analysis of the combined success rate for these four studies showed that pulp capping with MTA for partial pulpotomy had a higher success rate than with calcium hydroxide, although the difference did not reach significance.

These results showed that there was no significant difference in the clinical success rate between MTA versus biodentine, irrespective of the intervention, including direct pulp capping, partial pulpotomy, and full pulpotomy. These results are in accord with the systematic review and meta-analysis by Cushley et al. [5]. This non-significant difference may be attributable to the similar biological properties of biodentine and MTA [24], whose main component is calcium silicate, albeit in different ratios. In addition, both materials are biocompatible with pulp tissue and have low cytotoxicity [28].

The main limitation of this study was that subgroup analysis of other factors that might possibly affect clinical success, such as the root canal irrigation solution and types of restorative material, was not conducted. Moreover, all of the 21 selected studies were RCTs, which would have limited the number of studies selected for meta-analysis. On the basis of the present systematic review and meta-analysis, the following conclusions can be drawn: 1) For direct pulp capping, MTA yields a better clinical success rate than calcium hydroxide. 2) There is no difference in the clinical success rate between partial pulpotomy and full pulpotomy, irrespective of the pulp-capping material used. 3) There is no difference in the clinical success rate of VPT, irrespective of whether MTA or biodentine is used as the pulp-capping material for the same intervention.

Abbreviations

3Mix: mixture of three antibiotics; 95% CI: 95% confidence interval; BCs: bioceramic sealer; CEM: calcium-enriched mixture; CH: calcium hydroxide; DPC: direct pulp capping; EMD: enamel matrix derivative gel; FP: full pulpotomy; I²: heterogeneity; MTA: mineral trioxide aggregate; N_s: number of studies; N_t: number of treated teeth that were followed up in the last dental appointment recall; PP: partial pulpotomy; PRF: platelet-rich fibrin; RCT: randomized control trial; RCT: randomized controlled trial; RR: relative risk; Sample size (n): total participants; Sample size (t): total treated teeth; ns: not significant; VPT: vital pulp therapy

Ethical Statements

Ethical approval was not required for this systematic review.

Conflicts of Interest

The authors have no conflict of interest to declare.

Funding

Financial support from the Intramural Endowment Funds of the Faculty of Dentistry and Graduate School, Khon Kaen University, to N.P. and T.S., and the School of Dentistry, Mae Fah Luang University to S.K. is gratefully acknowledged.

Author Contributions

NP: conceptualization, methodology, investigation, data curation, visualization, writing- original draft; PC: methodology, validation, data curation, writing- review and editing draft; SK: methodology, validation, data curation, writing- original draft, funding acquisition. CN: resources, methodology, validation, formal analysis, writing- review and editing draft; NK: methodology, validation, Data curation, writing- review and editing draft; TS: conceptualization, methodology, validation, visualization, writing- original draft, supervision, project administration, funding acquisition. All authors reviewed and approved the final version of the manuscript.

ORCID iD

¹⁾NP: buttereel7@gmail.com, http://orcid.org/0009-0006-5715-0781

^1,2)PC: patchai@kku.ac.th, http://orcid.org/0000-0002-6520-6750

³⁾SK: suttichai.kri@mmfu.ac.th, http://orcid.org/0000-0001-9189-0333

⁴⁾CN: nchett@kku.ac.th, http://orcid.org/0000-0002-5737-5941

³⁾NK: nutthapong.kan@mfu.ac.th, http://orcid.org/0000-0001-9365-2929

¹⁾TS*: thasam@kku.ac.th, http://orcid.org/0009-0003-3968-2141

Acknowledgments

The authors would like to acknowledge Professor Dr. Malinee Laopaiboon, Assistant Professor Dr. Chantida Pawaputanon na mahasarakham, and Assistant Professor Pinpana Thaweesit for their helpful advice regarding the systematic review and meta-analysis. The authors also thank Dr. Thanapat Sastraruji, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand, for consultation on statistical presentation and manuscript writing.

Data Availability Statements

Data supporting the findings of this study are available from the corresponding author (T.S.) upon reasonable request.

References

Corresponding author

Funder information

1.Fund name: Intramural Endowment Funds of the Faculty of Dentistry and Graduate School, Khon Kaen University

2.Fund name: School of Dentistry, Mae Fah Luang University

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