What do systematic reviews say?

Mineral trioxide aggregate (MTA) vs Platelet-rich fibrin (PRF)

MTA and platelet-rich fibrin had comparable pulpotomy success (ungraded).

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

  >=12 months
  OR 1.02 [0.43, 2.43]
  3 studies · 109 participants
  GRADE not reported

Intervention not reported

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

  Partial pulpotomy, irreversible pulpitis
  Proportion 0.826 [0.754, 0.889]
  6 studies
  GRADE not reported

Intervention not reported

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

  Mixed root maturation (both mature and immature teeth)
  Proportion 0.950 [0.859, 0.998]
  3 studies
  GRADE not reported

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

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

The effect of MTA versus CH after pulpotomy is uncertain (low certainty).

• Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A… 2023 All outcomes

  1 to 2 years · Success after full or partial pulpotomy · Full or partial pulpotomy
  OR 2.36 [0.47, 11.75]
  6 studies · 341 participants
  Low

Platelet-rich fibrin (PRF) graft vs Mineral trioxide aggregate (MTA)

The two trials of PRF versus MTA for success gave contradictory results and were not pooled (ungraded).

• Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A… 2023 All outcomes

  ≥6 months follow-up · Dental/endodontic clinical settings across multiple countries (university, hospital, specialist and general dental practice); permanent teeth with carious pulp exposure
  PRF vs MTA was investigated in 2 RCTs (Alawwad 2020; Keswani 2014) for the primary outcome; the two trials provided contradictory evidence and differed in risk of bias, so were not pooled. Weak evidence.
  2 studies
  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

Calcium-enriched mixture (CEM) cement vs Mineral trioxide aggregate (MTA)

MTA and CEM performed comparably for clinical and radiographic success (2 RCTs, not pooled; ungraded).

• Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A… 2023 All outcomes

  ≥6 months follow-up · Dental/endodontic clinical settings across multiple countries (university, hospital, specialist and general dental practice); permanent teeth with carious pulp exposure
  CEM vs MTA was investigated in 2 RCTs (Asgary 2017; Nosrat 2013) for the primary outcome; not pooled owing to heterogeneity. The per-trial forest plots (Figure 8) indicated MTA performed comparably to CEM. Weak evidence.
  2 studies
  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

Pre-operative bone level < 35% vs Pre-operative bone level ≥ 35%

One study reported a 1.4% incidence with bone level < 35%.

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

  Bone level < 35%
  Proportion 1.4
  1 study
  GRADE not reported
• Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a… 2023 All outcomes

  Bone level ≥ 35%
  Proportion 0
  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

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

Evidence on dentin bridge formation for calcium hydroxide versus MTA is weak and imprecise, with no material shown superior (4 RCTs, not pooled; ungraded).

• Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A… 2023 All outcomes

  ≥6 months follow-up · Dental/endodontic clinical settings across multiple countries (university, hospital, specialist and general dental practice); permanent teeth with carious pulp exposure
  Four RCTs compared CH with MTA for dentin bridge formation (all used partial pulpotomy; all at low risk of bias except Qudeimat 2007). Apart from Wei 2010, trials yielded implausibly large ORs with very wide 95% CIs;…
  4 studies
  GRADE not reported

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

In immature teeth, the effect of MTA versus calcium hydroxide on success is very uncertain (OR 2.22, 95% CI 0.13-36.67; very low certainty).

• Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A… 2023 All outcomes

  ≥6 months; follow-up range 1-2 years · Dental/endodontic clinical settings across multiple countries (university, hospital, specialist and general dental practice); permanent teeth with carious pulp exposure · Root maturation: immature
  OR 2.22 [0.13, 36.67]
  2 studies · 106 participants
  Very low

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

For direct pulp capping, MTA probably achieves higher clinical and radiographic success than calcium hydroxide (OR 3.10, 95% CI 1.66-5.79; moderate certainty).

• Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A… 2023 All outcomes

  ≥6 months; follow-up range 1-3 years · Dental/endodontic clinical settings across multiple countries (university, hospital, specialist and general dental practice); permanent teeth with carious pulp exposure · Treatment performed: DPC
  OR 3.10 [1.66, 5.79]
  4 studies · 559 participants
  Moderate

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

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

In mixed-maturation teeth, the effect of MTA versus calcium hydroxide on success is very uncertain (OR 1.11, 95% CI 0.17-7.11; very low certainty).

• Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A… 2023 All outcomes

  ≥6 months; follow-up range 1-2 years · Dental/endodontic clinical settings across multiple countries (university, hospital, specialist and general dental practice); permanent teeth with carious pulp exposure · Root maturation: mixed
  OR 1.11 [0.17, 7.11]
  3 studies · 257 participants
  Very low

Biodentine vs Mineral trioxide aggregate (MTA)

More tooth discoloration was observed with MTA than with Biodentine, but odds ratios were implausibly large and not pooled (3 RCTs; ungraded).

• Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A… 2023 All outcomes

  ≥6 months follow-up · Dental/endodontic clinical settings across multiple countries (university, hospital, specialist and general dental practice); permanent teeth with carious pulp exposure
  Tooth discoloration was recorded in 4 trials; the 3 Biodentine-vs-MTA trials consistently showed more discoloration with MTA (Awawdeh 2018: 27/35 MTA vs 0/34 BD; Parinyaprom 2018: 11/31 MTA vs 0/29 BD; Uesrichai 2019:…
  3 studies
  GRADE not reported

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

The effect of MTA versus CH in immature teeth is very uncertain (very low certainty).

• Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A… 2023 All outcomes

  1 to 2 years · Success after vital pulp therapy · Immature teeth
  OR 2.22 [0.13, 36.67]
  2 studies · 106 participants
  Very low