Non-Cochrane · intervention · PM40394883
Effectiveness of calcium hydroxide compared to hydraulic calcium silicate cements for direct pulp capping in managing deep caries in vital permanent teeth: A systematic review and meta-analysis.
Herbst Sascha R, Pitchika Vinay, Herbst Chantal S, et al. · International endodontic journal · 2025 · PubMed · doi:10.1111/iej.14256
Oral HealthDental cariesEndodontics and dental traumaAMSTAR 2: High / Moderate (extractors disagree)
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
6
current version
GRADE rated
1
No studies
0
Included studies
9
linked below
No studies 0 · 0%Ungraded 5 · 83.3%Very low 0 · 0%Low 0 · 0%Moderate 1 · 16.7%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 | Mature or immature permanent teeth with deep or extremely deep caries and no symptoms or reversible pulpitis (asymptomatic pulp or reversible pulpitis), pulp exposure of cariogenic origin, dental dam used | 552 permanent teeth (mandibular/maxillary molars and premolars) with deep caries and asymptomatic or reversibly inflamed pulps; patients aged 7-69 years (5 RCTs) |
| Intervention | Direct pulp capping with calcium hydroxide (CaOH) | Direct pulp capping with CaOH (Dycal, Prevest DenPro, Hertz Pharmaceutical) (n=5 studies) |
| Comparison | Direct pulp capping with hydraulic calcium silicate cement (HCSC; e.g., MTA, Biodentine) | HCSC: MTA (ProRoot/White MTA, BioMTA+; n=4 studies) and Biodentine (Septodont; n=3 studies) |
| Outcomes | Primary: clinical and radiographic success. Secondary: patient-reported outcomes (postoperative pain, analgesic use) | Clinical and radiographic success reported in all 5 studies; postoperative pain reported in 2 studies (Suhag 2019, Kundzina 2017); no oral health-related quality-of-life data found |
| Study designs | Prospective comparative clinical trials in primary or secondary care | 5 randomized controlled trials (RCTs) |
| Timing | Clinical and radiographic success measured >=12 months after DPC; patient-reported outcomes >=7 days after DPC | Follow-up 12 months (3 studies) to 36 months (2 studies); postoperative pain assessed from 6 hours to 7 days |
Search date: 2025-02-19. Databases: MEDLINE via PubMed; EMBASE; Cochrane Database of Systematic Reviews
Questions and results
Hydraulic calcium silicate cements (HCSC; MTA or Biodentine) vs Calcium hydroxide (CaOH)
Population: Vital permanent teeth (mature or immature) with deep or extremely deep caries and asymptomatic pulp or reversible pulpitis, undergoing direct pulp capping
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success 36 months · 36-month follow-up 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). Source: Results, 'Clinical and radiographic success' (Figure 4; 36-month follow-up subgroup) · same question in other reviews | OR 2.34 [1.43, 3.84] | 2 studies · 379 participants | Ungraded |
Clinical and radiographic success 12 months · 12-month follow-up At 12-month follow-up, HCSC show higher odds of clinical and radiographic success than CaOH (OR 4.44, 95% CI 1.63 to 12.07; ungraded subgroup). Source: Results, 'Clinical and radiographic success' (Figure 4; 12-month follow-up subgroup) · same question in other reviews | OR 4.44 [1.63, 12.07] | 3 studies · 174 participants | Ungraded |
Clinical and radiographic success >=12 months Hydraulic calcium silicate cements probably increase clinical and radiographic success of direct pulp capping compared with calcium hydroxide (OR 2.68, 95% CI 1.70 to 4.22; moderate certainty). Source: Results, 'Clinical and radiographic success' (Figure 3); Abstract; 'Grading of evidence' (moderate certainty of evidence) · same question in other reviews | OR 2.68 [1.7, 4.22] | 5 studies · 552 participants | Moderate Downgraded: risk of bias |
Mineral trioxide aggregate (MTA) vs Calcium hydroxide (CaOH)
Population: Vital permanent teeth (mature or immature) with deep or extremely deep caries and asymptomatic pulp or reversible pulpitis, undergoing direct pulp capping
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success >=12 months Mineral trioxide aggregate shows higher odds of clinical and radiographic success than calcium hydroxide (OR 3.05, 95% CI 1.70 to 5.45; ungraded subgroup analysis). Source: Results, 'Clinical and radiographic success' (MTA vs CaOH; Figure 3) · same question in other reviews | OR 3.05 [1.70, 5.45] | 4 studies · 311 participants | Ungraded |
Postoperative pain (patient-reported) 6 hours to 7 days 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). Source: Results, 'Postoperative pain'; Discussion · same question in other reviews | 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 | Ungraded |
Biodentine (BD) vs Calcium hydroxide (CaOH)
Population: Vital permanent teeth (mature or immature) with deep or extremely deep caries and asymptomatic pulp or reversible pulpitis, undergoing direct pulp capping
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Clinical and radiographic success >=12 months Biodentine and calcium hydroxide did not differ significantly in clinical and radiographic success (OR 3.14, 95% CI 0.91 to 10.86; ungraded subgroup analysis). Source: Results, 'Clinical and radiographic success' (BD vs CaOH; Figure 3) · same question in other reviews | OR 3.14 [0.91, 10.86] | 3 studies · 242 participants | 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 | Yes | Partial Yes | no |
| 3Choice of study designs explained | No | No | yes |
| 4Comprehensive literature searchcritical | Partial Yes | Partial Yes | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | Yes | Yes | yes |
| 8Included studies described in detail | Yes | Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | NRSI: N/A · RCT: Yes | RCT: Yes | no |
| 10Funding of included studies reported | Yes | No | no |
| 11Appropriate meta-analysis methodscritical | NRSI: N/A · RCT: Yes | RCT: Yes | no |
| 12Impact of risk of bias on the pooled results | Yes | Yes | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | Yes | Yes | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | High | Moderate | no |
Included primary studies 9
Open as a trial list| Study | Also included by | Outcomes it informs here | Trial PICO | Results |
|---|---|---|---|---|
| Brizuela 2017 Direct Pulp Capping with Calcium Hydroxide, Mineral Trioxide Aggregate, and Biodentine in Permanent Young Teeth with Caries: A Randomized… DOI:10.1016/j.joen.2017.06.031 | this review only | not stated | not extracted yet | not extracted yet |
| Brizuela 2017 Direct Pulp Capping with Calcium Hydroxide, Mineral Trioxide Aggregate, and Biodentine in Permanent Young Teeth with Caries: A Randomized… PMID:28917577 | this review only | Clinical and radiographic success | not extracted yet | not extracted yet |
| Kundzina 2017 Capping carious exposures in adults: a randomized controlled trial investigating mineral trioxide aggregate versus calcium hydroxide DOI:10.1111/iej.12719 | this review only | not stated | not extracted yet | not extracted yet |
| Kundzina 2017 Capping carious exposures in adults: a randomized controlled trial investigating mineral trioxide aggregate versus calcium hydroxide. PMID:27891629 | this review only | Clinical and radiographic success | not extracted yet | not extracted yet |
| Peskersoy 2021 Efficacy of different calcium silicate materials as pulp-capping agents: Randomized clinical trial. PMID:33854725 | this review only | Clinical and radiographic success | not extracted yet | not extracted yet |
| Suhag 2019 Success of Direct Pulp Capping Using Mineral Trioxide Aggregate and Calcium Hydroxide in Mature Permanent Molars with Pulps Exposed during… DOI:10.1016/j.joen.2019.02.025 | this review only | not stated | not extracted yet | not extracted yet |
| Suhag 2019 Success of Direct Pulp Capping Using Mineral Trioxide Aggregate and Calcium Hydroxide in Mature Permanent Molars with Pulps Exposed during… PMID:31104819 | this review only | Clinical and radiographic success | not extracted yet | not extracted yet |
| Yavuz 2025 Examination of 6 and 12 month follow-up of calcium hydroxide and calcium silicate materials used in direct and indirect pulp capping DOI:10.17219/acem/194504 | this review only | not stated | not extracted yet | not extracted yet |
| Yavuz 2025 Examination of 6 and 12 month follow-up of calcium hydroxide and calcium silicate materials used in direct and indirect pulp capping. PMID:39932469 | this review only | Clinical and radiographic success | not extracted yet | not extracted yet |