Skip to main content

Advertisement

SpringerLink
Log in

Different materials for direct pulp capping: systematic review and meta-analysis and trial sequential analysis

  • Review
  • Published:
Clinical Oral Investigations Aims and scope Submit manuscript

Abstract

Objectives

We systematically assessed randomized controlled trials comparing direct pulp capping materials.

Methods

Trials comparing materials for direct capping and evaluating clinically and/or radiographically determined success after minimum 3 months were included. Two reviewers independently screened electronic databases (Medline, Central, Embase) and performed hand searches. Risk of bias was assessed and meta-analyses were performed, separated for dentition. Trial sequential analysis was used to assess risk of random errors. Strength of evidence was graded using the GRADE approach.

Results

From a total of 453 identified studies, 11 (all with high risk of bias) investigating 1094 teeth (922 patients) were included. Six studies were on primary teeth (all with carious exposures) and five on permanent teeth (carious and artificial exposures). Mean follow-up was 14 months (range 3–24). Most studies used calcium hydroxide as control, comparing it to mineral trioxide aggregate (MTA) (three studies), bonding without prior etching/conditioning (two), or bonding with prior etching/conditioning, enamel matrix proteins, resin-modified glass ionomer cement, calcium sulfate, zinc oxide eugenol, corticosteroids, antibiotics, or formocresol (each in only one study). One study compared MTA and calcium-enriched cement. In permanent teeth, risk of failure was significantly decreased if MTA instead of calcium hydroxide was used (risk ratio (RR) [95 % confidence intervals (CI)] 0.59 [0.39/0.90]); no difference was found for primary teeth. Other comparisons did not find significant differences or were supported by only one study. No firm evidence was reached according to trial sequential analysis.

Conclusion

There is insufficient data to recommend or refute the use of a specific material. More long-term practice-based studies with real-life exposures are required.

Clinical relevance

To reduce risk of failure, dentists might consider using MTA instead of calcium hydroxide (CH) for direct capping. Current evidence is insufficient for definitive recommendations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Aguilar P, Linsuwanont P (2011) Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review. J Endod 37:581–587

    Article  PubMed  Google Scholar 

  2. Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA (2006) The radiographic outcomes of direct pulp-capping procedures performed by dental students. J Am Dent Assoc 137:1699–1705

    Article  PubMed  Google Scholar 

  3. Aminabadi NA, Farahani RM, Gajan EB (2008) A clinical study of formocresol pulpotomy versus root canal therapy of vital primary incisors. J Clin Pediatr Dent 32:211–214

    Article  PubMed  Google Scholar 

  4. Aminabadi NA, Farahani RM, Oskouei SG (2010) Formocresol versus calcium hydroxide direct pulp capping of human primary molars: two year follow-up. J Clin Pediatr Dent 34:317–321

    Article  PubMed  Google Scholar 

  5. Andrews J, Guyatt G, Oxman AD, et al. (2013) GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol 66:719–725

    Article  PubMed  Google Scholar 

  6. Atkins D, Best D, Briss PA, et al. (2004) Grading quality of evidence and strength of recommendations. BMJ 328:1490

    Article  PubMed  Google Scholar 

  7. Barthel CR, Levin LG, Reisner HM, et al. (1997) TNF-alpha release in monocytes after exposure to calcium hydroxide treated Escherichia coli LPS. Int Endod J 30:155–159

    Article  PubMed  Google Scholar 

  8. Bergenholtz G (2000) Evidence for bacterial causation of adverse pulpal responses in resin-based dental restorations. Critical Rev Oral Biol Med Off Publ Am Assoc Oral Biologists 11:467–480

    Article  Google Scholar 

  9. Block RM, Lewis RD, Sheats JB, et al. (1978) Antibody formation to dog pulp tissue altered by formocresol within the root canal. Oral Surg Oral Med Oral Pathol 45:282–292

    Article  PubMed  Google Scholar 

  10. Brok J, Thorlund K, Wetterslev J, et al. (2009) Apparently conclusive meta-analyses may be inconclusive–trial sequential analysis adjustment of random error risk due to repetitive testing of accumulating data in apparently conclusive neonatal meta-analyses. Int J Epidemiol 38:287–298

    Article  PubMed  Google Scholar 

  11. Caplan DJ, Cai J, Yin G, et al. (2005) Root canal filled versus non-root canal filled teeth: a retrospective comparison of survival times. J Public Health Dent 65:90–96

    Article  PubMed  Google Scholar 

  12. Dammaschke T, Leidinger J, Schafer E (2010) Long-term evaluation of direct pulp capping–treatment outcomes over an average period of 6.1 years. Clin Oral Invest 14:559–567

    Article  Google Scholar 

  13. de Souza Costa CA, Hebling J, Hanks CT (2000) Current status of pulp capping with dentin adhesive systems: a review. Dent Mater 16:188–197

    Article  Google Scholar 

  14. Demets DL, Lan KKG (1994) Interim analysis: the alpha spending function approach. Stat Med 13:1341–1352

    Article  PubMed  Google Scholar 

  15. Demir T, Cehreli ZC (2007) Clinical and radiographic evaluation of adhesive pulp capping in primary molars following hemostasis with 1.25 % sodium hypochlorite: 2-year results. Am J Dent 20:182–188

    PubMed  Google Scholar 

  16. do Nascimento AB, Fontana UF, Teixeira HM, et al. (2000) Biocompatibility of a resin-modified glass-ionomer cement applied as pulp capping in human teeth. Am J Dent 13:28–34

    PubMed  Google Scholar 

  17. Dogan S, Duruturk L, Orhan AI, et al. (2013) Determining treatibility of primary teeth with pulpal exposure. J Clin Pediatr Dent 37:345–350

    Article  PubMed  Google Scholar 

  18. Duval S, Tweedie R (2000) Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56:455–463

    Article  PubMed  Google Scholar 

  19. Egger M, Smith GD, Schneider M, et al. (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315:629–634

    Article  PubMed  PubMed Central  Google Scholar 

  20. Fallahinejad Ghajari M, Asgharian Jeddi T, Iri S, et al. (2010) Direct pulp-capping with calcium enriched mixture in primary molar teeth: a randomized clinical trial. Iran Endod J 5:27–30

    PubMed  PubMed Central  Google Scholar 

  21. Fallahinejad Ghajari M, Asgharian Jeddi T, Iri S, et al. (2013) Treatment outcomes of primary molars direct pulp capping after 20 months: a randomized controlled trial. Iran Endod J 8:149–152

    PubMed  PubMed Central  Google Scholar 

  22. Ferk Luketic S, Malcic A, Jukic S, et al. (2008) Coronal microleakage of two root-end filling materials using a polymicrobial marker. J Endod 34:201–203

    Article  PubMed  Google Scholar 

  23. Fransson H, Wolf E, Petersson K (2015) Formation of a hard tissue barrier after experimental pulp capping or partial pulpotomy in humans: an updated systematic review. Int Endod J. doi:10.1111/iej.12480

    Google Scholar 

  24. Garrocho-Rangel A, Flores H, Silva-Herzog D, et al. (2009) Efficacy of EMD versus calcium hydroxide in direct pulp capping of primary molars: a randomized controlled clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107:733–738

    Article  PubMed  Google Scholar 

  25. Hewitt C, Hahn S, Torgerson DJ, et al. (2005) Adequacy and reporting of allocation concealment: review of recent trials published in four general medical journals. BMJ 330:1057–1058

    Article  PubMed  PubMed Central  Google Scholar 

  26. Higgins JPT, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions. Cochrane Collaboration, Version 5.10 (updated March 2011)

  27. Higgins JPT, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558

    Article  PubMed  Google Scholar 

  28. Hilton TJ (2009) Keys to clinical success with pulp capping: a review of the literature. Oper Dent 34:615–625

    Article  PubMed  PubMed Central  Google Scholar 

  29. Hilton TJ, Ferracane JL, Mancl L, et al. (2013) Comparison of CaOH with MTA for direct pulp capping: a PBRN randomized clinical trial. J Dent Res 92:S16–S22

    Article  PubMed Central  Google Scholar 

  30. Imberger G, Orr A, Thorlund K, et al. (2014) Does anaesthesia with nitrous oxide affect mortality or cardiovascular morbidity? A systematic review with meta-analysis and trial sequential analysis. Br J Anaesth 112:410–426

    Article  PubMed  Google Scholar 

  31. Iwamoto CE, Adachi E, Pameijer CH, et al. (2006) Clinical and histological evaluation of white ProRoot MTA in direct pulp capping. Am J Dent 19:85–90

    PubMed  Google Scholar 

  32. Keus F, Wetterslev J, Gluud C, et al. (2010) Trial sequential analyses of meta-analyses of complications in laparoscopic vs. small-incision cholecystectomy: more randomized patients are needed. J Clin Epidemiol 63:246–256

    Article  PubMed  Google Scholar 

  33. Li Z, Cao L, Fan M et al. (2015) Direct pulp capping with calcium hydroxide or mineral trioxide aggregate: a meta-analysis. J endod

  34. Lu Y, Liu T, Li H, et al. (2008) Histological evaluation of direct pulp capping with a self-etching adhesive and calcium hydroxide on human pulp tissue. Int Endod J 41:643–650

    Article  PubMed  Google Scholar 

  35. Lundh A, Sismondo S, Lexchin J et al. (2012) Industry sponsorship and research outcome. The Cochrane database of systematic reviews 12:Mr000033

  36. Macklin R (1999) The ethical problems with sham surgery in clinical research. N Engl J Med 341:992–996

    Article  PubMed  Google Scholar 

  37. Mejare IA, Axelsson S, Davidson T, et al. (2012) Diagnosis of the condition of the dental pulp: a systematic review. Int Endod J 45:597–613

    Article  PubMed  Google Scholar 

  38. Mente J, Hufnagel S, Leo M, et al. (2014) Treatment outcome of mineral trioxide aggregate or calcium hydroxide direct pulp capping: long-term results. J Endod 40:1746–1751

    Article  PubMed  Google Scholar 

  39. Miyashita H, Worthington H, Qualtrough A, et al. (2007) Pulp management for caries in adults: maintaining pulp vitality. Cochrane Database Syst Rev 18. doi:10.1002/14651858.CD004484.pub2

  40. Moher D, Liberati A, Tetzlaff J, DG A (2009) Preferred reporting items for systematic reviews and Meta-Analyses: the PRISMA statement. PLoS Med 6:e1000097

    Article  PubMed  PubMed Central  Google Scholar 

  41. Nakamura Y, Hammarstrom L, Lundberg E, et al. (2001) Enamel matrix derivative promotes reparative processes in the dental pulp. Adv Dent Res 15:105–107

    Article  PubMed  Google Scholar 

  42. O’brien PC, Fleming TR (1979) A multiple testing procedure for clinical trials. Biometrics 35:549–556

    Article  PubMed  Google Scholar 

  43. Ricucci D, Loghin S, Lin LM, et al. (2014) Is hard tissue formation in the dental pulp after the death of the primary odontoblasts a regenerative or a reparative process? J Dent 42:1156–1170

    Article  PubMed  Google Scholar 

  44. Sackett DL, Rosenberg WMC, Gray JM, et al. (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312:71–72

    Article  PubMed  PubMed Central  Google Scholar 

  45. Schroder U (1985) Effects of calcium hydroxide-containing pulp-capping agents on pulp cell migration, proliferation, and differentiation. Journal of dental research 64 Spec No:541–548

  46. Schulz KF, Grimes DA (2002) Blinding in randomised trials: hiding who got what. Lancet 359:696–700

    Article  PubMed  Google Scholar 

  47. Schuurs AH, Gruythuysen RJ, Wesselink PR (2000) Pulp capping with adhesive resin-based composite vs. calcium hydroxide: a review. Endod Dent Traumatol 16:240–250

    Article  PubMed  Google Scholar 

  48. Schwendicke F, Meyer-Lueckel H, Dorfer C, et al. (2013) Attitudes and behaviour regarding deep dentin caries removal: a survey among German dentists. Caries Res 47:566–573

    Article  PubMed  Google Scholar 

  49. Schwendicke F, Stolpe M (2014) Direct pulp capping following a carious exposure versus root canal treatment: a cost-effectiveness analysis. J Endod 40:1764–1770

    Article  PubMed  Google Scholar 

  50. Shovelton DS, Friend LA, Kirk EE, et al. (1971) The efficacy of pulp capping materials. Comp Trial Brit Dent J 130:385–391

    Article  Google Scholar 

  51. Smail-Faugeron V, Courson F, Durieux P et al. (2014) Pulp treatment for extensive decay in primary teeth. The Cochrane database of systematic reviews 8:Cd003220

  52. Stevenson HA, Harrison JE (2009) Structured abstracts: do they improve citation retrieval from dental journals? J Orthod 36:52–60 discussion 15-56

    Article  PubMed  Google Scholar 

  53. Sweeting MJ, Sutton AJ, Lambert PC (2004) What to add to nothing? Use and avoidance of continuity corrections in meta-analysis of sparse data. Stat Med 23:1351–1375

    Article  PubMed  Google Scholar 

  54. Thorlund K, Devereaux PJ, Wetterslev J, et al. (2009) Can trial sequential monitoring boundaries reduce spurious inferences from meta-analyses? Int J Epidemiol 38:276–286

    Article  PubMed  Google Scholar 

  55. Thorlund K, Engstrøm J, Wetterslev J et al. (2011) User manual for trial sequential analysis (TSA). http://www.ctu.dk/tsa/files/tsa_manual.pdf:1-115

  56. Tu YK, Faggion CMJ (2012) A primer on network meta-analysis for dental research. ISRN Dent Press 2012:276520. doi:10.5402/2012/276520

    Google Scholar 

  57. Tuna D, Olmez A (2008) Clinical long-term evaluation of MTA as a direct pulp capping material in primary teeth. Int Endod J 41:273–278

    Article  PubMed  Google Scholar 

  58. Ulusoy AT, Bayrak B, Bodrumlu EH (2014) Clinical and radiological evaluation of calcium sulfate as direct pulp capping material in primary teeth. Eur J Paediatr Dent Off J Eur Acad Paediatr Dent 15:127–131

    Article  Google Scholar 

  59. Wetterslev J, Thorlund K, Brok J, et al. (2008) Trial sequential analysis may establish when firm evidence is reached in cumulative meta-analysis. J Clin Epidemiol 61:64–75

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Operative and Preventive Dentistry, Charité−Universitätsmedizin Berlin, Aßmannshauser Str. 4-6, 14197, Berlin, Germany

    Falk Schwendicke, Fredrik Brouwer, Anja Schwendicke & Sebastian Paris

Authors
  1. Falk Schwendicke
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fredrik Brouwer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Anja Schwendicke
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sebastian Paris
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Falk Schwendicke.

Ethics declarations

None required.

Funding

This study was funded by the authors and their institutions.

Conflict of interest

The authors declare that they have no conflicts of interest.

Informed consent

Not applied.

This review was registered after the initial screening stage (PROSPERO CRD42015019514).

Electronic supplementary material

Table S1

Excluded studies. (DOCX 47 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schwendicke, F., Brouwer, F., Schwendicke, A. et al. Different materials for direct pulp capping: systematic review and meta-analysis and trial sequential analysis. Clin Oral Invest 20, 1121–1132 (2016). https://doi.org/10.1007/s00784-016-1802-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00784-016-1802-7

Keywords

Search

Navigation