Non-Cochrane · intervention · PM37710421
Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A systematic review and meta-analysis.
Fasoulas Athanasios, Keratiotis Georgios, Spineli Loukia, et al. · Clinical and experimental dental research · 2023 · PubMed · doi:10.1002/cre2.767
Full textEvery question was extracted from the full text, figures and supplements by two independent LLM extractors, disagreements adjudicated. Rows cite where in the review the value comes from.
Questions
19
current version
GRADE rated
12
No studies
0
Included studies
21
linked below
No studies 0 · 0%Ungraded 7 · 36.8%Very low 4 · 21.1%Low 4 · 21.1%Moderate 4 · 21.1%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | RCTs of patients with carious pulp exposure in one or more permanent teeth (reversible or irreversible pulpitis) treated with direct pulp capping, partial pulpotomy, or full pulpotomy | 21 RCTs (30 records) of patients with carious pulp exposure in permanent teeth; per-trial sample size 26-413 (median ~60) |
| Intervention | Any biomaterial used to cap the exposed/amputated pulp (e.g., calcium hydroxide, MTA, Biodentine, CEM, PRF); interventions and comparators deliberately not distinguished (all retrieved agents treated as of interest) | 10 capping materials formed the network; MTA (20 trials) and calcium hydroxide (14) most studied, then Biodentine (5), Theracal (3), PRF (3), CEM (2); also TAP, Abscess Remedy, Acemannan, nano-hydroxyapatite |
| Comparison | Any other capping biomaterial (network of all available materials) | Same 10-material network; only 31% of possible comparisons informed by >=1 trial |
| Outcomes | Primary: composite clinical and radiographic success at >=6 months. Secondary: continued root formation, tooth discoloration, dentin bridge formation | Primary success pooled only for CH vs MTA (OR 2.94, 95% CI 1.96-4.49; low certainty); secondary outcomes (root formation, discoloration, bridge formation) reported narratively without pooling |
| Study designs | Randomized controlled trials (including split-mouth and cluster RCTs) | 21 RCTs (17 two-arm, 3 three-arm, 1 four-arm); includes 1 split-mouth and cluster RCTs; RoB 2 overall moderate |
| Timing | Minimum 6 months follow-up; no restriction on publication date or language | Follow-up 1-3 years in the synthesized comparisons |
Search date: 28 February 2021 (from inception to 28/2/2021). Databases: MEDLINE via PubMed; Embase; Scopus; Web of Science; CENTRAL (Cochrane Library); ClinicalTrials.gov; WHO ICTRP; GreyLit; OpenGrey (Table 2)
Questions and results
Mineral trioxide aggregate (MTA) vs Calcium hydroxide (CH)
Population: Patients with carious pulp exposure in permanent teeth
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success 1 to 3 years · Unadjusted; all treatment modalities and root maturities MTA increases clinical and radiographic success versus CH (low certainty). Source: Figure 12; Results, Certainty of evidence · same question in other reviews | OR 2.94 [1.93, 4.49] 135 [72, 217] more per 1,000 | 10 studies · 900 participants | Low Downgraded: imprecision, inconsistency |
Dentin bridge formation ≥6 months follow-up Population: Patients with carious pulp exposure in permanent teeth undergoing partial pulpotomy Evidence on dentin bridge formation for calcium hydroxide versus MTA is weak and imprecise, with no material shown superior (4 RCTs, not pooled; ungraded). Source: Results 'Bridge formation'; Supporting Information Figure S4/Table S4 · same question in other reviews | 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 | Ungraded |
Clinical and radiographic success (composite) ≥6 months; follow-up range 1-3 years · Unadjusted (all CH vs MTA studies) Population: Patients with carious pulp exposure in permanent teeth undergoing DPC or pulpotomy (all treatment types and root-maturation stages combined; unadjusted) MTA achieved higher clinical and radiographic success than calcium hydroxide overall (OR 2.94, 95% CI 1.96-4.49; low certainty), but this unadjusted estimate pools clinically heterogeneous DPC and pulpotomy studies. Source: Figures 11-12 (GRADE Summary of Findings, 'Success (Unadjusted)'); Results 'Certainty of evidence'; Abstract · same question in other reviews | OR 2.94 [1.93, 4.49] 135 [72, 217] more successes per 1,000 with MTA | 10 studies · 900 participants | Low Downgraded: risk of bias, inconsistency |
Continued root formation / root development ≥6 months follow-up Population: Patients with carious pulp exposure in permanent teeth (predominantly immature) undergoing DPC or pulpotomy Evidence on continued root formation for calcium hydroxide versus MTA is weak and inconclusive (3 RCTs, not pooled; ungraded). Source: Results 'Tooth development'; Supporting Information Figure S3/Table S3; Discussion · same question in other reviews | CH vs MTA was the only informative comparison for root development (3 RCTs); estimates had implausibly wide 95% CIs, all including no difference, and two trials gave contradictory results (Qudeimat 2007 favored CH, OR… | 3 studies | Ungraded |
Mineral trioxide aggregate (MTA) vs Calcium hydroxide (CH)
Population: Patients with carious pulp exposure in permanent teeth undergoing direct pulp capping
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success 1 to 3 years · Direct pulp capping MTA increases clinical and radiographic success versus CH after direct pulp capping (moderate certainty). Source: Figure 11; Figure 9 · same question in other reviews | OR 3.10 [1.66, 5.79] 168 [61, 308] more per 1,000 | 4 studies · 559 participants | Moderate Downgraded: imprecision |
Clinical and radiographic success (composite) ≥6 months; follow-up range 1-3 years · Treatment performed: DPC Population: Patients with carious pulp exposure in permanent teeth undergoing direct pulp capping (DPC) 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). Source: Figure 11 (GRADE Summary of Findings, 'Success in DPC'); Figure 9 (forest plot); Results 'Subgroup analysis for treatment performed' · same question in other reviews | OR 3.10 [1.66, 5.79] 168 [61, 308] more successes per 1,000 with MTA | 4 studies · 559 participants | Moderate Downgraded: risk of bias |
Calcium hydroxide (CH) vs Mineral trioxide aggregate (MTA)
Population: Patients with carious pulp exposure in permanent teeth undergoing pulpotomy (partial or full)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success (composite) ≥6 months; follow-up range 1-2 years · Treatment performed: pulpotomy (FP/PP) For pulpotomy, whether MTA improves success over calcium hydroxide is uncertain (OR 2.36, 95% CI 0.47-11.75; low certainty; CI includes no effect). Source: Figure 11 (GRADE Summary of Findings, 'Success in Pulpotomy'); Figure 9 (forest plot) · same question in other reviews | OR 2.36 [0.47, 11.75] 74 [-32, 333] more successes per 1,000 with MTA (negative = fewer) | 6 studies · 341 participants | Low Downgraded: risk of bias, imprecision |
Clinical and radiographic success 1 to 2 years · Full or partial pulpotomy Population: Patients with carious pulp exposure in permanent teeth undergoing pulpotomy The effect of MTA versus CH after pulpotomy is uncertain (low certainty). Source: Figure 11; Figure 9 · same question in other reviews | OR 2.36 [0.47, 11.75] 74 [-32, 378] more per 1,000 | 6 studies · 341 participants | Low Downgraded: imprecision, inconsistency |
Calcium hydroxide (CH) vs Mineral trioxide aggregate (MTA)
Population: Patients with carious pulp exposure in mature permanent teeth
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success (composite) ≥6 months; follow-up range 1-3 years · Root maturation: mature In mature teeth, MTA probably achieves higher clinical and radiographic success than calcium hydroxide (OR 3.34, 95% CI 1.81-6.17; moderate certainty). Source: Figure 12 (GRADE Summary of Findings, 'Success in Mature teeth'); Figure 10 (forest plot); Results 'Subgroup analysis for root maturation' · same question in other reviews | OR 3.34 [1.81, 6.17] 207 [85, 393] more successes per 1,000 with MTA | 5 studies · 537 participants | Moderate Downgraded: risk of bias |
Clinical and radiographic success 1 to 3 years · Mature teeth MTA increases clinical and radiographic success versus CH in mature teeth (moderate certainty). Source: Figure 12; Figure 10 · same question in other reviews | OR 3.34 [1.81, 6.17] 207 [85, 355] more per 1,000 | 5 studies · 537 participants | Moderate Downgraded: imprecision |
Calcium hydroxide (CH) vs Mineral trioxide aggregate (MTA)
Population: Patients with carious pulp exposure in immature permanent teeth
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success (composite) ≥6 months; follow-up range 1-2 years · Root maturation: immature 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). Source: Figure 12 (GRADE Summary of Findings, 'Success in Immature teeth'); Figure 10 (forest plot) · same question in other reviews | OR 2.22 [0.13, 36.67] 22 [-17, 395] more successes per 1,000 with MTA (negative = fewer) | 2 studies · 106 participants | Very low Downgraded: risk of bias, imprecision |
Clinical and radiographic success 1 to 2 years · Immature teeth The effect of MTA versus CH in immature teeth is very uncertain (very low certainty). Source: Figure 12; Figure 10 · same question in other reviews | OR 2.22 [0.13, 36.67] | 2 studies · 106 participants | Very low Downgraded: imprecision |
Calcium hydroxide (CH) vs Mineral trioxide aggregate (MTA)
Population: Patients with carious pulp exposure in permanent teeth of mixed/unspecified root maturation
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success (composite) ≥6 months; follow-up range 1-2 years · Root maturation: mixed 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). Source: Figure 12 (GRADE Summary of Findings, 'Success in Mixed developed teeth'); Figure 10 (forest plot) · same question in other reviews | OR 1.11 [0.17, 7.11] 5 [-37, 207] more successes per 1,000 with MTA (negative = fewer) | 3 studies · 257 participants | Very low Downgraded: risk of bias, imprecision |
Clinical and radiographic success 1 to 2 years · Mixed root development Population: Patients with carious pulp exposure in permanent teeth with mixed root development The effect of MTA versus CH in teeth with mixed root development is very uncertain (very low certainty). Source: Figure 12; Figure 10 · same question in other reviews | OR 1.11 [0.17, 7.11] | 3 studies · 257 participants | Very low Downgraded: imprecision |
Biodentine vs Mineral trioxide aggregate (MTA)
Population: Patients with carious pulp exposure in permanent teeth undergoing DPC or pulpotomy
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Tooth discoloration ≥6 months follow-up More tooth discoloration was observed with MTA than with Biodentine, but odds ratios were implausibly large and not pooled (3 RCTs; ungraded). Source: Results 'Tooth discoloration'; Discussion · same question in other reviews | 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 | Ungraded |
Clinical and radiographic success (composite) ≥6 months follow-up MTA and Biodentine performed comparably for clinical and radiographic success (5 RCTs, not pooled; ungraded). Source: Results 'Study characteristics' and 'Primary outcome' (Figure 8 forest-plot panel); Discussion · same question in other reviews | Biodentine vs MTA was the second most frequent comparison (5 RCTs) for the primary outcome but was not pooled owing to substantial clinical/statistical heterogeneity; the panel of per-trial forest plots (Figure 8)… | 5 studies | Ungraded |
Calcium-enriched mixture (CEM) vs Mineral trioxide aggregate (MTA)
Population: Patients with carious pulp exposure in permanent teeth undergoing pulpotomy
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success (composite) ≥6 months follow-up MTA and CEM performed comparably for clinical and radiographic success (2 RCTs, not pooled; ungraded). Source: Results 'Study characteristics'; Discussion (Figure 8) · same question in other reviews | 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 | Ungraded |
Calcium hydroxide (CH) vs Biodentine
Population: Patients with carious pulp exposure in permanent teeth undergoing DPC or pulpotomy
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success (composite) ≥6 months follow-up Biodentine appeared to perform better than calcium hydroxide for success, but the evidence was not pooled (2 RCTs; ungraded). Source: Results 'Study characteristics'; Discussion (Figure 8) · same question in other reviews | CH vs Biodentine was investigated in 2 RCTs for the primary outcome; not pooled. Biodentine appeared to perform better than CH (and than Theracal) in the per-trial forest plots (Figure 8). Weak evidence. | 2 studies | Ungraded |
Platelet-rich fibrin (PRF) vs Mineral trioxide aggregate (MTA)
Population: Patients with carious pulp exposure in immature permanent teeth undergoing pulpotomy
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success (composite) ≥6 months follow-up The two trials of PRF versus MTA for success gave contradictory results and were not pooled (ungraded). Source: Results 'Primary outcome' (PRF vs MTA); Discussion · same question in other reviews | 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 | Ungraded |
AMSTAR 2 appraisal
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | Partial Yes | Partial Yes | yes |
| 3Choice of study designs explained | Yes | Yes | yes |
| 4Comprehensive literature searchcritical | Yes | Yes | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | No | No | yes |
| 8Included studies described in detail | Yes | Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: Yes · NRSI: N/A | NRSI: N/A · RCT: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: Yes · NRSI: N/A | NRSI: N/A · RCT: Yes | no |
| 12Impact of risk of bias on the pooled results | No | No | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | No | No | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | Critically Low | Critically Low | yes |
Included primary studies 21
Open as a trial list| Study | Also included by | Outcomes it informs here | Trial PICO | Results |
|---|---|---|---|---|
| Asgary et al. 2017 matched by author and year (probable) | 1 other review | not stated | not extracted yet | not extracted yet |
| Alawwad et al. 2020 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Awawdeh et al. 2018 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Brizuela et al. 2017 matched by author and year (probable) | this review only | Clinical and radiographic success (composite) | not extracted yet | not extracted yet |
| Cengiz & Yilmaz 2016 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Cengiz 2016 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Chailertvanitkul et al. 2014 matched by author and year (probable) | this review only | Clinical and radiographic success (composite) | not extracted yet | not extracted yet |
| El-Meligy & Avery 2006 matched by author and year (probable) | this review only | Clinical and radiographic success (composite) | not extracted yet | not extracted yet |
| Eppa et al. 2018 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Keswani et al. 2014 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Kumar et al. 2016 matched by author and year (probable) | this review only | Clinical and radiographic success (composite) | not extracted yet | not extracted yet |
| Kundzina et al. 2017 matched by author and year (probable) | this review only | Clinical and radiographic success (composite) | not extracted yet | not extracted yet |
| Nosrat et al. 2013 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Ozgur 2017 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Parinyaprom et al. 2018 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Peskersoy et al. 2021 matched by author and year (probable) | this review only | Clinical and radiographic success (composite) | not extracted yet | not extracted yet |
| Qudeimat et al. 2007 matched by author and year (probable) | this review only | Clinical and radiographic success (composite) | not extracted yet | not extracted yet |
| Suhag et al. 2019 matched by author and year (probable) | this review only | Clinical and radiographic success (composite) | not extracted yet | not extracted yet |
| Taha & Khazali 2017 matched by author and year (probable) | this review only | Clinical and radiographic success (composite) | not extracted yet | not extracted yet |
| Taha 2017 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
| Uesrichai et al. 2019 matched by author and year (probable) | this review only | not stated | not extracted yet | not extracted yet |
Overlap with other reviews
Reviews that include the same primary studies are not independent evidence. Shared counts match studies by PMID, DOI or NCT, and otherwise by author and year (a probable match).
| Review | Shared studies | Jaccard |
|---|---|---|
| Outcome of pulpotomy in permanent teeth with irreversible pulpitis: a systematic review and meta-analysis. (2022) | 1 | 0.03 |