What do systematic reviews say?

Conditioning and sealing with an adhesive resin (smear-removing bonding system) vs Conventional calcium hydroxide lining

• Pulp management for caries in adults: maintaining pulp vitality 2007 · Cochrane All outcomes

  36 months
  Whitworth 2005: 602 teeth randomised; 39 emergency recalls over the 36 months after restoration, with pulp breakdown associated with 16 teeth. The authors concluded that "dentists should be confident that pulps will be…
  1 study · 602 participants
  GRADE not reported

Extra-oral pulp extirpation at day 0 vs Intra-oral pulp extirpation at day 7

• Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted 2019 · Cochrane All outcomes
  Giannetti 2006 did not report this outcome; following email correspondence, authors reported no adverse effects were seen (uncertain whether formally assessed).
  1 study
  GRADE not reported

Extra-oral pulp extirpation at day 0 vs Intra-oral pulp extirpation at day 7

It is very uncertain whether extra-oral pulp extirpation at day 0 changes radiographic resorption (proxy measure for periodontal healing) at… compared with intra-oral pulp extirpation at day 7 (very low certainty).

• Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted 2019 · Cochrane All outcomes

  12 months
  RR 1.35 [0.81, 2.24]
  1 study · 19 participants
  Very low

Indirect restorations (crowns, fixed partial dentures, inlays/onlays/veneers) vs None (single-group incidence)

Pulp necrosis incidence among treated by prosthodontists was 1.87% (subgroup analysis; not GRADE-rated).

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Follow-up ≤5 to >10 years · University clinics and dental practices, multiple countries · Treated by prosthodontists
  Proportion 1.87 [0.84, 3.31]
  3834 participants
  GRADE not reported
• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Follow-up ≤5 to >10 years · University clinics and dental practices, multiple countries · PFM fabrication material
  Proportion 5.71 [0.12, 18.75]
  1980 participants
  GRADE not reported
• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  >5-10 years · University clinics and dental practices, multiple countries · Follow-up >5-10 years
  Proportion 5.53 [3.74, 7.64]
  2443 participants
  GRADE not reported

Tooth location

One study reported a 7.1% incidence in mandibular posterior teeth.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Kontakiotis et al. 2015 mandibular posterior
  Proportion 7.1
  1 study
  GRADE not reported
• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Cheung et al. 2005 mandibular anterior
  Proportion 0
  1 study
  GRADE not reported
• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Cheung et al. 2005 mandibular posterior
  Proportion 6.1
  1 study
  GRADE not reported

Indirect restoration placement by undergraduate students vs None (single-group incidence)

The pooled incidence with undergraduate students was 5.68%.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Undergraduate students
  Proportion 5.68 [3.17, 8.86]
  1604 participants
  GRADE not reported
• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  General practitioners
  Proportion 4.44 [2.16, 7.49]
  2113 participants
  GRADE not reported

Pre-operative caries fillings or crowns vs Intact teeth

One study reported a 13% incidence in teeth with pre-operative caries fillings or crowns.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Pre-operative caries fillings or crowns
  Proportion 13
  1 study
  GRADE not reported
• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Intact teeth
  Proportion 5
  1 study
  GRADE not reported

Eugenol-based temporary cement vs Eugenol-free temporary cement

The pooled incidence with eugenol-based temporary cement was 3.34%.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Eugenol-based
  Proportion 3.34 [1.66, 5.58]
  7043 participants
  GRADE not reported
• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Eugenol-free
  Proportion 5.77 [3.72, 8.24]
  639 participants
  GRADE not reported

Intervention not reported

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Reversible hydrocolloid impression material
  Proportion 1.19
  1 study
  GRADE not reported

Glass ionomer (GIC) permanent cement vs Glass ionomer cement or zinc phosphate cement

The pooled incidence with GIC permanent cement was 5.33%.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  GIC
  Proportion 5.33 [2.56, 9.03]
  182 participants
  GRADE not reported

Indirect restorations (crowns, fixed partial dentures, inlays/onlays/veneers) vs Follow-up duration

The pooled incidence with > 5–10 years of follow-up was 5.53%.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  > 5–10 years · > 5–10 years
  Proportion 5.53 [3.74, 7.64]
  2443 participants
  GRADE not reported

Polyether impression material vs Polyvinyl siloxane impression material

The pooled incidence with polyether impression material was 4.02%.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Polyether
  Proportion 4.02 [2.47, 5.92]
  2985 participants
  GRADE not reported
• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Polyvinyl siloxane
  Proportion 3.17 [1.55, 5.34]
  636 participants
  GRADE not reported

Ceramic restoration material vs Porcelain-fused-to-metal restoration material

The pooled incidence with ceramic restorations was 5.59%.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Ceramic
  Proportion 5.59 [2.89, 9.12]
  460 participants
  GRADE not reported

Zinc polycarboxylate cement

One study reported a 1.1% incidence with zinc polycarboxylate permanent cement.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Zinc polycarboxylate
  Proportion 1.1
  1 study
  GRADE not reported

Intervention not reported

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Compound impression material
  Proportion 3.27
  1 study
  GRADE not reported

Indirect restorations (crowns, fixed partial dentures, inlays/onlays/veneers) vs None (single-group incidence)

The pooled incidence with ≤ 5 years of follow-up was 3.53%.

• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  ≤ 5 years · ≤ 5 years
  Proportion 3.53 [2.10, 5.31]
  5532 participants
  Low

Hyperbaric oxygen (following replantation) vs control

It is very uncertain whether hyperbaric oxygen (following replantation) changes pulpal healing at 12 months compared with control (very low certainty).

• Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted 2019 · Cochrane All outcomes

  12 months
  RR 1.25 [1.06, 1.48]
  1 study · 69 participants
  Very low

Mineral trioxide aggregate (MTA) vs Calcium hydroxide (CH)

In partial pulpotomy, MTA had significantly higher success than calcium hydroxide (OR 2.81; ungraded).

• Efficacy of pulpotomy for permanent teeth with carious pulp exposure: A systematic review and meta-analysis of… 2024 All outcomes

  >=12 months · Partial pulpotomy
  OR 2.81 [1.38, 5.74]
  Studies not reported
  GRADE not reported
• Efficacy of pulpotomy for permanent teeth with carious pulp exposure: A systematic review and meta-analysis of… 2024 All outcomes

  >=12 months · Mature teeth
  OR 2.63 [1.14, 6.03]
  Studies not reported
  GRADE not reported
• Efficacy of pulpotomy for permanent teeth with carious pulp exposure: A systematic review and meta-analysis of… 2024 All outcomes

  >=12 months
  OR 2.41 [1.28, 4.51]
  7 studies · 377 participants
  Low

Mineral trioxide aggregate (MTA) vs Calcium hydroxide (CH)

The effect of material choice (MTA vs CaOH) on postoperative pain is unclear: two small studies used different methods and reported contradictory results, so no meta-analysis was performed (ungraded).

• Effectiveness of calcium hydroxide compared to hydraulic calcium silicate cements for direct pulp capping in managing… 2025 All outcomes

  6 hours to 7 days · Primary or secondary dental care
  Two studies assessed postoperative pain; no meta-analysis was performed due to methodological heterogeneity. Suhag 2019: significantly higher pain in CaOH than MTA at 18 h (CaOH 18.5 +/- 20.8 mm vs MTA 6.3 +/- 9.5 mm,…
  2 studies
  GRADE not reported

Hydraulic calcium silicate cements (HCSC; MTA or Biodentine) vs Calcium hydroxide (CH)

At 36-month follow-up, HCSC show higher odds of clinical and radiographic success than CaOH (OR 2.34, 95% CI 1.43 to 3.84; ungraded subgroup).

• Effectiveness of calcium hydroxide compared to hydraulic calcium silicate cements for direct pulp capping in managing… 2025 All outcomes

  36 months · Primary or secondary dental care · 36-month follow-up
  OR 2.34 [1.43, 3.84]
  2 studies · 379 participants
  GRADE not reported
• Effectiveness of calcium hydroxide compared to hydraulic calcium silicate cements for direct pulp capping in managing… 2025 All outcomes

  12 months · Primary or secondary dental care · 12-month follow-up
  OR 4.44 [1.63, 12.07]
  3 studies · 174 participants
  GRADE not reported
• Effectiveness of calcium hydroxide compared to hydraulic calcium silicate cements for direct pulp capping in managing… 2025 All outcomes

  >=12 months · Primary or secondary dental care
  OR 2.68 [1.7, 4.22]
  5 studies · 552 participants
  Moderate