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Outcome of Partial Pulpotomy in Cariously Exposed Posterior Permanent Teeth: A Systematic Review and Meta-analysis

Published:September 09, 2019DOI:https://doi.org/10.1016/j.joen.2019.07.005

      Abstract

      Introduction

      The current systematic review and meta-analysis aimed to evaluate the success rate of partial pulpotomy in treating permanent posterior teeth with carious vital pulp exposure. A secondary aim was to assess the prognostic factors using a meta-regression.

      Methods

      An electronic search was performed for studies from January 1950 to November 2018 in the following databases: PubMed, ScienceDirect, and Cochrane. All searches were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical studies evaluating the success rate of cariously exposed vital human permanent posterior teeth treated with a partial pulpotomy were selected. Only randomized clinical trials and prospective clinical studies were included for evaluation. The Newcastle-Ottawa Scale and the Cochrane Collaboration’s tool were used to evaluate risk assessment.

      Results

      From the 218 studies identified through the initial search, 11 studies qualified for the final analysis (5 randomized clinical trials and 6 prospective studies). The results of the meta-analysis indicate a success rate of 98% (confidence interval [CI]: 0.94–1), 96% (CI: 0.92–0.99), and 92% (CI: 0.83–0.97) after 6 months and 1 and 2 years of follow-up. Examining the probable prognostic factors using meta-regression analysis, only preoperative pulp status (P = .001) was identified as a significant factor, with studies including teeth with the presumptive diagnosis of irreversible pulpitis displaying significantly lower results. The final solution, pulp capping material, apex closure, and the age of the patient did not affect the treatment success rate (P > .05).

      Conclusions

      The available data suggest that a partial pulpotomy results in high success rates in treating cariously exposed permanent posterior teeth up to 2 years. Six months of monitoring can be considered an appropriate period when evaluating the success of a partial pulpotomy although more clinical and radiographic controls are essential to ensuring success.

      Key Words

      A partial pulpotomy can be considered a reliable conservative treatment option for treating cariously exposed permanent posterior teeth, presenting high success rates in different follow-up periods. Cases with the presumptive diagnosis of irreversible pulpitis presented a lower success rate and should be treated with caution.
      According to the recommendations made at the International Caries Consensus Collaboration meeting in Leuven, Belgium, in 2015, the maintenance of pulpal health should be a primary goal in treating deep carious lesions
      • Schwendicke F.
      • Frencken J.E.
      • Bjørndal L.
      • et al.
      Managing carious lesions: consensus recommendations on carious tissue removal.
      . Pulp exposure should be avoided whenever possible by adopting the less invasive approach of incomplete or selective caries removal
      • Schwendicke F.
      • Frencken J.E.
      • Bjørndal L.
      • et al.
      Managing carious lesions: consensus recommendations on carious tissue removal.
      . However, even using a more conservative approach, pulp exposure is sometimes inevitable
      • Hoefler V.
      • Nagaoka H.
      • Miller C.S.
      Long-term survival and vitality outcomes of permanent teeth following deep caries treatment with step-wise and partial-caries-removal: a systematic review.
      . In cases in which pulp exposure is inevitable, root canal treatment (RCT) is considered as the treatment of choice because it has a considerably high success and survival rate
      • Stoll R.
      • Betke K.
      • Stachniss V.
      The influence of different factors on the survival of root canal fillings: a 10-year retrospective study.
      • Ng Y.L.
      • Mann V.
      • Rahbaran S.
      • et al.
      Outcome of primary root canal treatment: systematic review of the literature—part 2: influence of clinical factors.
      . Nevertheless, a more conservative approach should be considered for the management of pulp exposures in vital teeth. Vital pulp therapy treatment modalities have been introduced as an alternative to RCT. They include indirect and direct pulp capping, partial pulpotomy, and complete pulpotomy
      • Swift Jr., E.J.
      • Trope M.
      • Ritter A.V.
      Vital pulp therapy for mature tooth: can it work?.
      • Ghoddusi J.
      • Forghani M.
      • Parisay I.
      New approaches in vital pulp therapy in permanent teeth.
      . These techniques promote the possibility of continued tooth vitality along with functional and structural healing of the pulp-dentin complex by preserving the remaining pulp tissue
      • Zhang W.
      • Yelick P.C.
      Vital pulp therapy-current progress of dental pulp regeneration and revascularization.
      • Witherspoon D.E.
      Vital pulp therapy with new materials: new directions and treatment perspectives--permanent teeth.
      . In addition, these treatments present the opportunity for a cost-effective and less technique-sensitive approach when compared with RCT
      • Asgary S.
      • Eghbal M.J.
      • Ghoddusi J.
      • Yazdani S.
      One-year results of vital pulp therapy in permanent molars with irreversible pulpitis: an ongoing multicenter, randomized, non-inferiority clinical trial.
      . The choice of treatment is usually based on the presumption diagnosis of each case. However, doubts remain about the criteria that must be taken into account when choosing the optimal treatment. It has been stated that the effectiveness of healing or biological regeneration depends on the degree of inflammation of the pulp tissue
      • Fong C.D.
      • Davis M.J.
      Partial pulpotomy for immature permanent teeth, its present and future.
      . In deep carious lesions, inflammation in the superficial layers of the pulp is more pronounced compared with that in the deeper layers. Despite the presence of some dilatation of the blood vessels, the pulp tissue in the root canal remains normal
      • Fong C.D.
      • Davis M.J.
      Partial pulpotomy for immature permanent teeth, its present and future.
      • Solomon R.V.
      • Faizuddin U.
      • Karunakar P.
      • et al.
      Coronal pulpotomy technique analysis as an alternative to pulpectomy for preserving the tooth vitality, in the context of tissue regeneration: a correlated clinical study across 4 adult permanent molars.
      .
      A partial pulpotomy consists of the amputation of 2–3 mm of pulp tissue below the exposed pulp. This treatment is used in cases in which the exposed pulp tissue is considered to be damaged or affected
      • Cvek M.
      A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture.
      . Amputating the infected tissue before capping the exposure may offer a higher chance of healing when compared with capping the affected tissue as in a direct pulp capping procedure
      • Kiatwateeratana T.
      • Kintarak S.
      • Piwat S.
      • et al.
      Partial pulpotomy on caries-free teeth using enamel matrix derivative or calcium hydroxide: a randomized controlled trial.
      • Aguilar P.
      • Linsuwanont P.
      Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review.
      . In contrast, partial pulpotomy is considered a more conservative approach in comparison with complete pulpotomy. Nevertheless, a partial pulpotomy still offers the benefit of preserving the cell-rich coronal pulp, which ensures the continual deposition of cervical dentin and reduces the risk of root canal obliteration
      • Fong C.D.
      • Davis M.J.
      Partial pulpotomy for immature permanent teeth, its present and future.
      • Barrieshi-Nusair K.M.
      • Qudeimat M.A.
      A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth.
      .
      According to the literature, the success rate of vital pulp treatments varies widely according to the type of study
      • Barrieshi-Nusair K.M.
      • Qudeimat M.A.
      A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth.
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      . In the case of cariously exposed pulp, it is essential to have sufficient evidence when choosing an appropriate treatment plan. Nevertheless, the literature exhibits a lack of high-degree evidence examining this treatment option, solely presenting 1 systematic review almost a decade ago
      • Aguilar P.
      • Linsuwanont P.
      Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review.
      . Furthermore, a recent review
      • Alqaderi H.
      • Lee C.T.
      • Borzangy S.
      • Pagonis T.C.
      Coronal pulpotomy for cariously exposed permanent posterior teeth with closed apices: a systematic review and meta-analysis.
      noted that it had several limitations, including pooling of the follow-up periods, inconsistent success criteria, and inclusion of different approaches for carious tissue removal such as the stepwise approach. Moreover, only 2 studies included used mineral trioxide aggregate (MTA) as the capping material. Hydraulic calcium silicate cements are often proposed as an alternative to calcium hydroxide (CH) for vital pulp therapy procedures because they induce a more rapid formation of a less porous and thicker hard tissue barrier
      • Aeinehchi M.
      • Eslami B.
      • Ghanbariha M.
      • Saffar A.S.
      Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human teeth: a preliminary report.
      • Cox C.F.
      • Sübay R.K.
      • Ostro E.
      • et al.
      Tunnel defects in dentin bridges: their formation following direct pulp capping.
      .
      The last decade has seen a considerable increase in the number of clinical studies using MTA or MTA-like cements as a pulp capping material
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      • Chailertvanitkul P.
      • Paphangkorakit J.
      • Sooksantisakoonchai N.
      • et al.
      Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars.
      • Peng C.
      • Zhao Y.
      • Yang Y.
      • Qin M.
      • Kang C.M.
      • Sun Y.
      • Song J.S.
      • et al.
      A randomized controlled trial of various MTA materials for partial pulpotomy in permanent teeth.
      • Özgür B.
      • Uysal S.
      • Güngör H.C.
      Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials.
      , providing more cases for reevaluating the effectiveness of this treatment method. The main aim of this systematic review and meta-analysis was to evaluate the success rate of a partial pulpotomy in treating permanent posterior teeth with carious vital pulp exposure. A secondary aim was to assess the confounding prognostic factors using a meta-regression.

      Material and Methods

      The present systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses principles
      • Hutton B.
      • Salanti G.
      • Caldwell D.M.
      • et al.
      The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.
      . Population, Intervention, and Outcome items of the PICO framework were used to formulate the following clinically related question: What is the success rate of performing a partial pulpotomy in treating permanent posterior vital teeth with carious pulp exposure?

       Search Strategy

      The online search was conducted independently by 2 of the investigators (F.M. and J.G.O.) in the following databases: PubMed (National Center for Biotechnology Information, US National Library of Medicine), ScienceDirect (Elsevier, RELX Group, Amsterdam, Netherlands), and Cochrane (John Wiley & Sons, Ltd, London, UK). The following combination of key words was used including partial pulpotomy, miniature pulpotomy, and pulp curettage (partial[All Fields] AND ("pulpotomy"[MeSH Terms] OR "pulpotomy"[All Fields]) OR miniature[All Fields] AND ("pulpotomy"[MeSH Terms] OR "pulpotomy"[All Fields]) OR ("dental pulp"[MeSH Terms] OR ("dental"[All Fields] AND "pulp"[All Fields]) OR "dental pulp"[All Fields] OR "pulp"[All Fields]) AND ("curettage"[MeSH Terms] OR "curettage"[All Fields]). Studies published from January 1950 to November 2018 were included in the search with no language restriction. In addition, the reference lists of the selected studies were revised to find possible relevant studies, and gray literature was also searched including OpenGrey. Also, a hand search was performed in the following journals: Journal of Dentistry; Journal of Endodontics; International Endodontic Journal; Australian Endodontic Journal; and Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. Study authors were contacted privately via e-mail whenever any doubts were encountered about the study.

       Study Selection

       Inclusion and Exclusion Criteria

      The current review was set to select clinical studies evaluating the success rate of cariously exposed vital human permanent posterior teeth treated with a partial pulpotomy. Only randomized clinical trials and prospective clinical studies were included for evaluation. A follow-up period of a minimum of 6 months and a sample size of at least 10 teeth were required for review inclusion. A follow-up rate of a minimum of 80% was required for study inclusion. The success rate had to be available or at least calculable from the data provided. In addition, only studies that reported outcome data including pain, tenderness to palpation/percussion, and other clinical and radiographic signs of inflammation or necrosis or root resorption were included.

       Data Extraction

      A flow diagram of the search process was performed with the number of excluded/included articles. After the first screening and evaluation of all the articles according to title and abstract, the same 2 investigators assessed the full text for all potential studies to be included. In the event that the full-text article was not available, the authors were personally contacted by e-mail to gain access to the full-text article. An Excel spreadsheet (Microsoft Office; Microsoft, Redmond, WA) was created with the following information for each study: study design, presumption diagnosis, level of pulp amputation, pulp capping material, time of follow-up, time for hemostasis, hemostatic solution, patient’s age, sex, apex status, sample size, number of dropouts, success rate, time before final restoration, and type of final restoration. The studies that did not meet the inclusion criteria, including primary teeth studies, were excluded.

       Quality Assessment

      The quality assessment of the selected studies was performed according to the design of each study. The Newcastle-Ottawa scale was used for risk assessment of prospective cohort studies

      Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed April 12, 2015.

      . For randomized clinical trials, the Cochrane Collaboration’s tool was used

      Higgins JPT, Altman DG, Sterne JAC, eds. Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Churchill R, Chandler J, Cumpston MS, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.2.0, Cochrane, 2017. Available from www.training.cochrane.org/handbook. Accessed September 9, 2019.

      . In addition, the level of evidence for each study was graded using the Oxford Centre for Evidence-based Medicine levels of evidence recommendations. Two investigators independently performed the risk assessment and evidence level rating (F.M. and X.F.R.). In case of disagreement, a consensus was reached by discussion with a third investigator (J.G.O).

       Statistical Analysis and Synthesis of Results

      The metafor package version 2.0 of the R software (Free Software Foundation, Boston, MA) was used for data analysis. A level of statistical significance of 5% was set. For the studies that reported raw transfer frequency data, the proportions were calculated by dividing the number of cases considered as a success among the total exposed (without taking into account the lost data). The transformation of Freeman-Tukey double arcsine was applied to stabilize the variances.
      The data were analyzed for 6 months and 1 and 2 years with 2 groups according to the study design (ie, randomized clinical trial or prospective studies). The heterogeneity between studies was measured with the Cochran Q test and the value of I2 (values of I2 >60% were considered as significant heterogeneity). A random-effects model was conducted. Sensitivity analysis was predetermined to evaluate and isolate the effect of the results of the different studies in the global result. Meta-regression analysis was adjusted to determine if success could be modulated with prespecified factors including preoperative pulp diagnosis, final solution, pulp capping material, age, apex closure, and type of study. In case of heterogeneity, subgroup analysis was performed, and the results were visualized with a forest plot, and publication bias was evaluated with the funnel plot and Egger contrast.

      Results

       Study Selection

      The process of selecting the included studies is described in Figure 1. Twenty-five studies underwent full-text review. Reasons for study exclusion are presented in Table 1. Eleven studies
      • Barrieshi-Nusair K.M.
      • Qudeimat M.A.
      A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth.
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      • Chailertvanitkul P.
      • Paphangkorakit J.
      • Sooksantisakoonchai N.
      • et al.
      Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars.
      • Peng C.
      • Zhao Y.
      • Yang Y.
      • Qin M.
      • Kang C.M.
      • Sun Y.
      • Song J.S.
      • et al.
      A randomized controlled trial of various MTA materials for partial pulpotomy in permanent teeth.
      • Özgür B.
      • Uysal S.
      • Güngör H.C.
      Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials.
      • Baratieri L.N.
      • Monteiro Jr., S.
      • Caldeira de Andrada M.A.
      Pulp curettage--surgical technique.
      • Mass E.
      • Zilberman U.
      Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars.
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      • Mass E.
      • Zilberman U.
      Long-term radiologic pulp evaluation after partial pulpotomy in young permanent molars.
      were included in the final analysis. Table 2 presents the features of the included studies. Two investigators independently performed all the search steps and reviewed all the studies (F.M. and J.G.O.). In case of disagreement, a consensus was reached through discussion.
      Table 1The Excluded Articles and the Reason for Exclusion
      ArticleReason for exclusion
      Bakhtiar et al, 2017
      • Bakhtiar H.
      • Nekoofar M.H.
      • Aminishakib P.
      • et al.
      Human pulp responses to partial pulpotomy treatment with TheraCal as compared with biodentine and proRoot MTA: a clinical trial.


      Sübay et al, 1995
      • Sübay R.K.
      • Suzuki S.
      • Suzuki S.
      • et al.
      Human pulp response after partial pulpotomy with two calcium hydroxide products.
      Used sound teeth
      Eren et al, 2017
      • Eren B.
      • Onay E.O.
      • Ungor M.
      Assessment of alternative emergency treatments for symptomatic irreversible pulpitis: a randomized clinical trial.
      Follow-up less than 6 months
      Bjørndal et al, 2017
      • Bjørndal L.
      • Fransson H.
      • Bruun G.
      • et al.
      Randomized clinical trials on deep carious lesions: 5-year follow-up.


      Asgary et al, 2018
      • Asgary S.
      • Hassanizadeh R.
      • Torabzadeh H.
      • Eghbal M.J.
      Treatment outcomes of 4 vital pulp therapies in mature molars.


      Kang et al, 2017
      • Kang C.M.
      • Sun Y.
      • Song J.S.
      • et al.
      A randomized controlled trial of various MTA materials for partial pulpotomy in permanent teeth.
      Only results at 1 year excluded.
      Loss to follow-up more than 20%
      Asgary et al, 2014
      • Asgary S.
      • Fazlyab M.
      • Sabbagh S.
      • Eghbal M.J.
      Outcomes of different vital pulp therapy techniques on symptomatic permanent teeth: a case series.
      Case series
      Awawdeh et al, 2018
      • Awawdeh L.
      • Al-Qudah A.
      • Hamouri H.
      • Chakra R.J.
      Outcomes of vital pulp therapy using mineral trioxide aggregate or Biodentine: a prospective randomized clinical trial.


      Nosrat et al, 2013
      • Nosrat A.
      • Seifi A.
      • Asgary S.
      Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate: a randomized clinical trial.
      Performed complete pulpotomy
      Bjørndal et al. 2010
      • Bjørndal L.
      • Reit C.
      • Bruun G.
      • et al.
      Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy.


      Zilberman et al. 1989
      • Zilberman U.
      • Mass E.
      • Sarnat H.
      Partial pulpotomy in carious permanent molars.
      Duplicated reports
      Nosrat & Nosrat, 1998
      • Nosrat I.V.
      • Nosrat C.A.
      Reparative hard tissue formation following calcium hydroxide application after partial pulpotomy in cariously exposed pulps of permanent teeth.
      Sample size less than 10
      Mass et al, 1995
      • Mass E.
      • Zilberman U.
      • Fuks A.B.
      Partial pulpotomy: another treatment option for cariously exposed permanent molars.


      Janicha & Wacinska-Drapinśka, 1986
      • Janicha J.
      • Wacinska-Drapinśka M.
      A new technic for the partial amputation of the pulp chamber in tooth diseases in growing patients [in Polish].
      Review
      Only results at 1 year excluded.
      Table 2A Summary of the Included Studies
      StudyStudy typeSampleAge (years) (mean±SD)Follow-up months (mean±SD)Pulp capping materialRestoration (n)Apex (n)Preoperative pulp diagnosis (n)
      Baratieri, 1989
      • Baratieri L.N.
      • Monteiro Jr., S.
      • Caldeira de Andrada M.A.
      Pulp curettage--surgical technique.
      Prospective study2512–44 (22.1±8.98)8–36 (18±6.11)CHAmalgamClosedNormal/reversible
      Mass, 1993
      • Mass E.
      • Zilberman U.
      Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars.
      Prospective study357.5–25 (12.5)12–>48CHAmalgam (29)

      SS crown (6)
      Closed (26)

      Open (9)
      Normal/reversible
      Mejare, 1993
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      Prospective study226–15 (9)24–140 (56)CHAmalgam CompositeClosed/openNormal/reversible (17)

      Irreversible (5)
      Barrieshi-Nusair, 2006
      • Barrieshi-Nusair K.M.
      • Qudeimat M.A.
      A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth.
      Prospective study287.2–13.1 (10)12–26 (17.5)MTAAmalgam

      SS Crown
      Closed (24)

      Open (7)
      Normal/reversible
      Qudeimat, 2007
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      Randomized clinical trial516.8–13.3 (10.3±1.8)25.4–45.6 (34.8±4.4)CH (32)

      MTA (32)
      Amalgam (22)

      Composite (9)

      SS crown (33)
      Closed (46)

      Open (18)
      Normal/reversible
      Mass, 2011
      • Mass E.
      • Zilberman U.
      Long-term radiologic pulp evaluation after partial pulpotomy in young permanent molars.
      Prospective study496.9–17.7 (11.4)12–154 (49)CHAmalgam (33)

      Composite (3)

      SS crown (13)
      Closed (43)

      Open (6)
      Normal/reversible
      Chailertvanitkul, 2014
      • Chailertvanitkul P.
      • Paphangkorakit J.
      • Sooksantisakoonchai N.
      • et al.
      Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars.
      Randomized clinical trial847–103–24CH (40)

      MTA (44)
      AmalgamOpenNormal/reversible
      Peng, 2015
      • Peng C.
      • Zhao Y.
      • Yang Y.
      • Qin M.
      Prospective study106.1–15.4 (10.17±3.01)12MTACompositeOpenIrreversible
      Kang, 2017
      • Kang C.M.
      • Sun Y.
      • Song J.S.
      • et al.
      A randomized controlled trial of various MTA materials for partial pulpotomy in permanent teeth.
      Randomized clinical trial83(29.3±14.8)1 to 12MTAComposite

      Indirect restoration
      ClosedNormal/reversible
      Özgür, 2017
      • Özgür B.
      • Uysal S.
      • Güngör H.C.
      Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials.
      Randomized clinical trial796–13 (8.57±1.25)6–24 (23±3.98)CH (40)

      MTA (40)
      CompositeOpenNormal/reversible
      Taha, 2017
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      Randomized clinical trial4620–52 (30.3±9.6)6–24CH (23)

      MTA (27)
      Amalgam (22)

      Composite (27)
      ClosedIrreversible
      CH, calcium hydroxide; MTA, mineral trioxide aggregate–like material; SD, standard deviation; SS, stainless steel.

       Quality Assessment

      In general, the randomized clinical trials evaluated
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      • Chailertvanitkul P.
      • Paphangkorakit J.
      • Sooksantisakoonchai N.
      • et al.
      Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars.
      • Kang C.M.
      • Sun Y.
      • Song J.S.
      • et al.
      A randomized controlled trial of various MTA materials for partial pulpotomy in permanent teeth.
      • Özgür B.
      • Uysal S.
      • Güngör H.C.
      Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials.
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      displayed a low risk of bias in the different items evaluated (Fig. 2). In 1 study
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      , allocation concealment was performed according to a table of random allocation; there is insufficient information to permit judgment whether the table was available for the operator(s) before patient selection. Thus, unclear risk was selected. Because of the treatment nature, blinding of the operators did not seem possible. Material selection could be blinded to the patient in the different studies but not the dentists who performed the procedure. Nevertheless, the primary aim of the review was to evaluate the success rate of a partial pulpotomy as a procedure and not a capping material comparison although material as a variable was further evaluated via meta-regression. In this case, the outcome was not likely influenced by the lack of operator blinding. Thus, unclear risk was selected for all included studies for this item. Regarding blinding of outcome assessment, in 1 study
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      , all follow-up examinations were performed by 1 of the investigators; whether this investigator was aware of the treatment details of each patient remains unknown with the available information, and accordingly unclear risk was selected. No other biases were found across the included studies. For the Newcastle-Ottawa scale assessment, 4 studies reported a good quality
      • Barrieshi-Nusair K.M.
      • Qudeimat M.A.
      A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth.
      • Peng C.
      • Zhao Y.
      • Yang Y.
      • Qin M.
      • Baratieri L.N.
      • Monteiro Jr., S.
      • Caldeira de Andrada M.A.
      Pulp curettage--surgical technique.
      • Mass E.
      • Zilberman U.
      Long-term radiologic pulp evaluation after partial pulpotomy in young permanent molars.
      and 3 a fair quality
      • Nosrat A.
      • Seifi A.
      • Asgary S.
      Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate: a randomized clinical trial.
      • Mass E.
      • Zilberman U.
      Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars.
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      according to the Agency for Healthcare Research and Quality standards. The main reasons were regarding comparability and outcome blinding of the evaluators (Fig. 2).
      Figure thumbnail gr2
      Figure 2A risk of bias summary for the different studies. (A) Cochrane Collaboration’s tool for randomized controlled trials and (B) Newcastle-Ottawa quality assessment scale for cohort studies.

       Summary of Results

       6-month Results

      After combining the 5 randomized clinical trials
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      • Chailertvanitkul P.
      • Paphangkorakit J.
      • Sooksantisakoonchai N.
      • et al.
      Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars.
      • Kang C.M.
      • Sun Y.
      • Song J.S.
      • et al.
      A randomized controlled trial of various MTA materials for partial pulpotomy in permanent teeth.
      • Özgür B.
      • Uysal S.
      • Güngör H.C.
      Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials.
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      , based on a random-effects model, the reported success rate at the 6-month follow-up was 0.96 (confidence interval [CI], 0.87–1), with significant heterogeneity across the studies (I2 = 88.47%). For the 6 prospective studies
      • Barrieshi-Nusair K.M.
      • Qudeimat M.A.
      A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth.
      • Peng C.
      • Zhao Y.
      • Yang Y.
      • Qin M.
      • Baratieri L.N.
      • Monteiro Jr., S.
      • Caldeira de Andrada M.A.
      Pulp curettage--surgical technique.
      • Mass E.
      • Zilberman U.
      Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars.
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      • Mass E.
      • Zilberman U.
      Long-term radiologic pulp evaluation after partial pulpotomy in young permanent molars.
      , based on the random-effects model, the success rate at 6 months was 0.99 (CI, 0.97–1), with an absence of heterogeneity (I2 = 6.48%). When combining all the studies, there was significant heterogeneity across the studies (I2 = 72.9%). Thus, a random-effects model was used, which reported a success rate of 0.98 (CI, 0.94–1; Fig. 3).
      Figure thumbnail gr3
      Figure 3The 6-month, 1-year, and 2-year meta-analysis results.

       1-year Results

      The pooled rate based on a random-effects model for the 4 randomized clinical trials
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      • Chailertvanitkul P.
      • Paphangkorakit J.
      • Sooksantisakoonchai N.
      • et al.
      Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars.
      • Özgür B.
      • Uysal S.
      • Güngör H.C.
      Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials.
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      was 0.94 (CI, 0.81–1), with significant heterogeneity across the studies (I2 = 90.52% and 0.98; CI, 0.94–1) for the 6 prospective studies
      • Barrieshi-Nusair K.M.
      • Qudeimat M.A.
      A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth.
      • Peng C.
      • Zhao Y.
      • Yang Y.
      • Qin M.
      • Baratieri L.N.
      • Monteiro Jr., S.
      • Caldeira de Andrada M.A.
      Pulp curettage--surgical technique.
      • Mass E.
      • Zilberman U.
      Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars.
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      • Mass E.
      • Zilberman U.
      Long-term radiologic pulp evaluation after partial pulpotomy in young permanent molars.
      and an absence of heterogeneity (I2 = 4.42%). When combining all the studies, a random-effects model was used (I2 = 72.4%), which reported a success rate of 0.96 (CI, 0.91–0.99; Fig. 3).

       2-year Results

      The success rate based on a random-effects model for the 4 randomized clinical trials
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      • Chailertvanitkul P.
      • Paphangkorakit J.
      • Sooksantisakoonchai N.
      • et al.
      Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars.
      • Özgür B.
      • Uysal S.
      • Güngör H.C.
      Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials.
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      was 0.91 (CI, 0.76–1), with significant heterogeneity across the studies (I2 = 91.35%). For the 3 prospective studies
      • Mass E.
      • Zilberman U.
      Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars.
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      • Mass E.
      • Zilberman U.
      Long-term radiologic pulp evaluation after partial pulpotomy in young permanent molars.
      , the pooled rate was 0.92 (CI, 0.85–0.97), with an absence of heterogeneity (I2 = 0%). When analyzing all the studies together, it resulted in a significant heterogeneity across all the studies (I2 = 80.7%). The random-effects model reported a success rate of 0.92 (CI, 0.83–0.97; Fig. 3).

       Additional Analysis

      Sensitivity analysis revealed that only 1 study
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      modified the results in the 3 evaluated periods. At the 6-month period, the estimated proportion was 0.99 (CI, 0.93–0.98), with a heterogeneity of I2 = 11.58%. At the 1-year follow-up, the estimated proportion was 0.98 (CI, 0.96–0.99), with a heterogeneity of I2 = 0%. After 2 years, the estimated proportion was 0.96 (CI, 0.93–0.98), with a heterogeneity of I2 = 0%. The heterogeneity results are primarily caused by the results from the study of Taha and Khazali
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      , more precisely by the CH group in that study, in which the outcome rates were low when compared with the rest of the results (62%, 55%, and 43% for the 6-month, 1-year, and 2-year follow-up). The results observed in the funnel plot were almost symmetrical (Supplemental Fig. 1), and the P-value of the Egger test was .89 for the reversible group and .23 for the irreversible group, which suggest no significant publication bias, except for the study of Taha and Khazali
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      , which presents slightly different results. This can explain the heterogeneity observed among the randomized clinical trials, especially considering that this heterogeneity was not observed in the separate analysis of the prospective studies (Supplemental Table S2).
      Using meta-regression analysis, preoperative pulp status (P = .001) was the only variable significantly associated with the success rate at the 1-year follow-up period (Table 3, Supplemental Table S2). According to subgroup analysis, the success rate for teeth diagnosed as irreversible pulpitis at the 12-month follow-up was 0.75 (CI, 0.62–0.86) compared with 0.98 (CI, 0.96–1) in studies with teeth diagnosed as reversible pulpitis (Fig. 4).
      Table 3Meta-regression Analysis of the Effect of Clinical Variables on the Success Rate after 1 Year
      Dependent variableWeighted mean 1-year success rate
      Independent variableCoefficient (CI)P value
      Capping materials (ref: CH)
       MTA0.04 (−0.06 to 0.16).438
      Pulp status (ref: irreversible)
       Reversible0.31 (0.13–0.50).001
      Study type (ref: prospective)
       Randomized clinical trials−0.02 (−0.16 to 0.12).751
      Age−0.01 (−0.05 to 0.02).366
      Apex
       Closed (ref: no)−0.01 (−0.19 to 0.17).920
       Open (ref: no)−0.24 (−0.79 to 0.29).377
      CH, calcium hydroxide; CI, confidence interval; MTA, mineral trioxide aggregate.
      Figure thumbnail gr4
      Figure 4The success rate after 1 year according to the preoperative pulp diagnosis.

      Discussion

      According to the results of the present systematic review and meta-analysis, a partial pulpotomy is an adequate treatment option when treating carious exposures in permanent posterior teeth. It presents a high success rate in different follow-up periods although there is no accurate established timing for when a partial pulpotomy can be considered a success. However, in a similar treatment, Matsuo et al
      • Matsuo T.
      • Nakanishi T.
      • Shimizu H.
      • Ebisu S.
      A clinical study of direct pulp capping applied to carious-exposed pulps.
      considered 21 months as the appropriate time to determine a successful prognosis for direct pulp capping. They also considered 3 months as adequate for a tentative prognosis because no differences were found from 3 to 18 months. This is in accordance with the results of this review in which the success rate did not result in statistical differences among the 3 evaluation periods (6 months, 1 year, and 2 years). Thus, 6 months can be considered as a suitable period when evaluating success after a partial pulpotomy. Although treatment can be considered a success in a consensual period, patients already should be scheduled for regular annual visits according to the American Dental Association recommendations for low-risk patients
      • Giannobile W.V.
      • Braun T.M.
      • Caplis A.K.
      • et al.
      Patient stratification for preventive care in dentistry.
      were clinical controls, and also radiographic evaluation, when considered necessary, should be performed to assure the success of the treatment.”
      Zanini et al
      • Zanini M.
      • Hennequin M.
      • Cousson P.Y.
      A review of criteria for the evaluation of pulpotomy outcomes in mature permanent teeth.
      pointed out that for long periods of examination, the possible reason for failure or bacteria pathway should be described. In accordance, restoration status and the periodontal condition at the time of the failure should be reported. However, studies included in this review do not provide this information
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      • Chailertvanitkul P.
      • Paphangkorakit J.
      • Sooksantisakoonchai N.
      • et al.
      Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars.
      • Özgür B.
      • Uysal S.
      • Güngör H.C.
      Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials.
      • Mass E.
      • Zilberman U.
      Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars.
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      • Mass E.
      • Zilberman U.
      Long-term radiologic pulp evaluation after partial pulpotomy in young permanent molars.
      . Possibly as a future recommendation, the periodontal condition and restoration status of the tooth should be reported at the time of failure in order to try to determine if the failure was related to external factors or the vital pulp therapy itself.
      Clinical and radiographic signs and symptoms in failure cases (Supplemental Table S1) can be divided into immediate/early and late/delayed failures. Theoretically, early failures should be associated with an inflammatory process
      • Zanini M.
      • Hennequin M.
      • Cousson P.Y.
      A review of criteria for the evaluation of pulpotomy outcomes in mature permanent teeth.
      , which was commonly expressed as spontaneous pain in the selected studies, and, thus, root canal treatment was performed. Because final restorations were placed in the same visit in 9 of 11 studies and a healthy periodontal status was a prerequisite in all the studies, thus eliminating any possible pathway for bacterial contamination, it can be assumed that the treatment itself was the reason for failure. Necrosis and periapical involvement were mainly associated with delayed failures where bacterial infection may be involved. In more extended follow-up periods, bacterial leakage could play a role as coronal barriers of the restoration, and the newly formed dentinal bridge can no longer protect the underlying pulp tissue. However, some cases with spontaneous pain were also reported after a 2-year follow-up period, indicating that an irreversible radicular pulpitis event can also be presented as a late event and not only in the first 2 months as reported previously in coronal pulpotomies
      • Zanini M.
      • Hennequin M.
      • Cousson P.Y.
      A review of criteria for the evaluation of pulpotomy outcomes in mature permanent teeth.
      . Another possible explanation is that in those cases pulp status was inadequately diagnosed, and inflammation was further progressed apically than previously thought.
      The longer the observation period is, the higher the risk of patient loss to follow-up. A loss to follow-up of more than 20% carries a threat to the validity of the results
      • Strauss S.
      • Glasziou P.
      • Richardson W.
      • Haynes R.
      Evidence-Based Medicine: How to Practice and Teach EBM.
      ; hence, articles with a follow-up rate lower than 80% were excluded to avoid this unwanted effect
      • Bjørndal L.
      • Fransson H.
      • Bruun G.
      • et al.
      Randomized clinical trials on deep carious lesions: 5-year follow-up.
      • Asgary S.
      • Hassanizadeh R.
      • Torabzadeh H.
      • Eghbal M.J.
      Treatment outcomes of 4 vital pulp therapies in mature molars.
      . The study by Kang et al
      • Kang C.M.
      • Sun Y.
      • Song J.S.
      • et al.
      A randomized controlled trial of various MTA materials for partial pulpotomy in permanent teeth.
      was included even though at the 1-year follow-up a dropout rate of 26% was reported. Thus, only the results at the 6-month follow-up period were included for statistical analysis. An attempt was made to include studies with a similar clinical protocol. Subsequently, articles that used different treatment approaches were excluded. In their study, Mejàre and Cvek
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      included 15 teeth in which before performing the partial pulpotomy a stepwise carious tissue removal approach with CH was performed to avoid pulp exposure. A stepwise approach before performing a partial pulpotomy can modify the pulp-dentin complex defense mechanism by inducing the formation of secondary dentin and pausing the caries progression
      • Magnusson B.O.
      • Sundell S.O.
      Stepwise excavation of deep carious lesions in primary molars.
      • Leksell E.
      • Ridell K.
      • Cvek M.
      • Mèjare I.
      Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth.
      .
      Only the preoperative pulp status held significance and could explain the variance in results between the studies and thus can be considered as a potential prognostic factor (P < .0001). In cases of presumption diagnosis of normal pulp or reversible pulpitis, a partial pulpotomy results in a 1-year success rate of 98% (CI, 96–99). This result is comparable when performing a complete pulpotomy under the same initial diagnosis
      • Alqaderi H.
      • Lee C.T.
      • Borzangy S.
      • Pagonis T.C.
      Coronal pulpotomy for cariously exposed permanent posterior teeth with closed apices: a systematic review and meta-analysis.
      . Thus, a partial pulpotomy should be selected in those cases as being a more conservative approach with a similar outcome. Studies with the presumption diagnosis of irreversible pulpitis had a lower success rate compared with the other studies (75% CI, 62–86). This could be explained by the fact that in a more advanced stage, pulp inflammation will further progress apically in the pulp complex. Thus, removing only the coronal 2–3 mm might not be enough to eliminate all the affected tissue, which may jeopardize the healing response, and a less conservative approach should be considered such as coronal pulpotomy or a root canal treatment. However, only 2 studies
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      • Peng C.
      • Zhao Y.
      • Yang Y.
      • Qin M.
      including cases with presumption diagnosis of irreversible pulpitis were available for analysis with a total sample of 62 teeth. Therefore, these results should be interpreted with caution, and further studies are needed to estimate the validity of this factor accurately.
      Neither the patient’s age nor the root apex closure results affect the prognosis of a partial pulpotomy. It has to be highlighted that age was evaluated as mean ± standard deviation in every study, and data of specific failures were not available. However, studies included patients aged 6–52 years old. Young patients’ pulp is more cellular and has been considered to have a higher potential for healing compared with older patients’ pulp, which is more fibrous and less cellular with a reduced blood supply
      • Massler M.
      Therapy conductive to healing of the human pulp.
      . However, studies include older patients ranging from 25–52 years old with no significant differences when compared with younger patients
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      • Kang C.M.
      • Sun Y.
      • Song J.S.
      • et al.
      A randomized controlled trial of various MTA materials for partial pulpotomy in permanent teeth.
      • Baratieri L.N.
      • Monteiro Jr., S.
      • Caldeira de Andrada M.A.
      Pulp curettage--surgical technique.
      • Mass E.
      • Zilberman U.
      Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars.
      . Similarly, most studies included involved mature teeth with a closed apex with no significant differences when compared with immature teeth with an open apex
      • Barrieshi-Nusair K.M.
      • Qudeimat M.A.
      A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth.
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      • Mass E.
      • Zilberman U.
      Long-term radiologic pulp evaluation after partial pulpotomy in young permanent molars.
      . This is more relevant because traditionally vital pulp therapy treatment has been recommended as a treatment exclusively for young patients with immature apices
      • Cvek M.
      A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture.
      • Langeland K.
      • Dowden W.E.
      • Tronstad L.
      • Langeland L.K.
      Human pulp changes of iatrogenic origin.
      • Berk H.
      • Krakow A.A.
      A comparison of the management of pulpal pathosis in deciduous and permanent teeth.
      . The current review may indicate that partial pulpotomy could be effective in both mature and immature teeth.
      MTA and MTA-like materials have been introduced as an alternative to CH in vital pulp therapy treatments. For many years, CH was considered as the material of choice in pulp capping procedures
      • Stanley H.R.
      • Lundy T.
      Dycal for pulp exposures.
      • Siqueira J.F.
      • Lopes H.P.
      Mechanisms of antimicrobial activity of calcium hydroxide: a critical review.
      • Mohammadi Z.
      • Dummer P.M.
      Properties and applications of calcium hydroxide in endodontics and dental traumatology.
      . However, CH tends to reabsorb over time and degradation to bending. In addition, it is soluble in oral fluids, and it has a low mechanical resistance that could result in microfiltration over long periods
      • Aeinehchi M.
      • Eslami B.
      • Ghanbariha M.
      • Saffar A.S.
      Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human teeth: a preliminary report.
      • Cox C.F.
      • Sübay R.K.
      • Ostro E.
      • et al.
      Tunnel defects in dentin bridges: their formation following direct pulp capping.
      • Silva A.F.
      • Tarquinio S.B.
      • Demarco F.F.
      • et al.
      The influence of haemostatic agents on healing of healthy human dental pulp tissue capped with calcium hydroxide.
      . Besides, MTA requires less time to produce a thicker dentinal bridge with fewer tunnel defects when compared with CH
      • Aeinehchi M.
      • Eslami B.
      • Ghanbariha M.
      • Saffar A.S.
      Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human teeth: a preliminary report.
      . Taking all that into account and that bacterial leakage is regarded as the primary cause of failure of vital pulp therapies
      • Massler M.
      Therapy conductive to healing of the human pulp.
      , MTA-like materials should result in an improved success rate. However, there was no significant difference in the results obtained by both materials in either direct or indirect comparison, suggesting that either material could be used clinically with a similar prognosis. Aguilar and Linsuwanont
      • Aguilar P.
      • Linsuwanont P.
      Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review.
      reported that partial pulpotomy with CH resulted in a higher success rate in an indirect comparison. Differences can be caused by the sample size because at that time only 2 studies included MTA-like materials for evaluation.
      Barthel et al
      • Barthel C.R.
      • Rosenkranz B.
      • Leuenberg A.
      • Roulet J.F.
      Pulp capping of carious exposures: treatment outcome after 5 and 10 years: a retrospective study.
      reported significantly higher success rates when the final restoration was placed within 2 days after direct pulp capping procedures. All the included studies in the present review placed the final resonation within this period, except for 2 studies
      • Baratieri L.N.
      • Monteiro Jr., S.
      • Caldeira de Andrada M.A.
      Pulp curettage--surgical technique.
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      in which the cavity was temporally restored with zinc oxide eugenol (ZOE) cement before placing the final restoration after 3 to 6 months. ZOE cements do not result in a fluid-tight seal under in vitro conditions and have not been considered as an appropriate interim restorative material in extensive cavities
      • Tewari S.
      • Tewari S.
      Assessment of coronal microleakage in intermediately restored endodontic access cavities.
      • Jensen A.L.
      • Abbott P.V.
      Experimental model: dye penetration of extensive interim restorations used during endodontic treatment while under load in a multiple axis chewing simulator.
      • Ciftçi A.
      • Vardarli D.A.
      • Sönmez I.S.
      Coronal microleakage of four endodontic temporary restorative materials: an in vitro study.
      . Nevertheless, although this delay in a definitive restoration placement with a temporary ZOE restoration seems not to affect the overall success rate under clinical conditions, it is recommended to perform the final restoration in the same visit to avoid the risk of microleakage. The risk of leakage can also be reduced by performing the tissue removal under a rubber dam isolation. However, not enough data were available to evaluate a statistical relationship. Only 23 of the 51 cases in the study by Queidmat et al
      • Qudeimat M.A.
      • Barrieshi-Nusair K.M.
      • Owais A.I.
      Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
      were performed with no rubber dam, and partial isolation with cotton rolls was performed. In their study, only 4 cases resulted in treatment failure, and all 4 cases were not isolated with a rubber dam. Thus, it is probably an appropriate recommendation to perform all the procedure under rubber dam isolation.
      There was a variation among the included studies regarding the type of the final restoration used, varying from amalgam, composite, and stainless steel crowns. Unfortunately, not enough data were available to study this variable as a prognostic factor, and analysis could not be performed. Even though various authors were contacted, not enough replies were received to perform the analysis.

      Conclusion

      According to the results of the present systematic review and meta-analysis, a partial pulpotomy is considered a reliable treatment option for the treatment of cariously exposed permanent posterior teeth. It presents a high success rate of 92% after 2 years. The preoperative pulp diagnosis results in a significant prognostic factor, and cases diagnosed as irreversible pulpitis result in a lower success rate. There is no significant difference between MTA-like materials and CH as a pulp capping agent nor the other variables evaluated.

      Acknowledgments

      The authors deny any conflicts of interest related to this study.

      Appendix

      Supplemental Table S1Clinical and Radiographic Signs and Symptoms in Failure Cases
      StudyClinical and radiographic Signs and symptomsObservation period
      Mejáre and Cvek, 1993
      • Mejàre I.
      • Cvek M.
      Partial pulpotomy in young permanent teeth with deep carious lesions.
      Pulpitis (pain)10 days
      Periapical radiolucency (2 teeth)10 and 24 months
      Mass and Zilberman, 1993
      • Mass E.
      • Zilberman U.
      Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars.
      Pulp necrosis (2 teeth)20 days and 17 months
      Mass and Zilberman, 2011
      • Mass E.
      • Zilberman U.
      Long-term radiologic pulp evaluation after partial pulpotomy in young permanent molars.
      Spontaneous pain (3 teeth)Did not specify
      Kang et al, 2017
      • Kang C.M.
      • Sun Y.
      • Song J.S.
      • et al.
      A randomized controlled trial of various MTA materials for partial pulpotomy in permanent teeth.
      Spontaneous pain (2 teeth)2 weeks and 1 month
      Sinus tract formation and periapical radiolucency5 months
      Özgür et al, 2017
      • Özgür B.
      • Uysal S.
      • Güngör H.C.
      Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials.
      Spontaneous pain and periapical radiolucency (2 teeth)6 months
      Taha and Khazali, 2017
      • Taha N.A.
      • Khazali M.A.
      Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial.
      Spontaneous pain (4 teeth)Immediate failure
      Spontaneous pain (4 teeth)6 months
      Negative response with periapical radiolucency (4 teeth)
      Pain on biting and periapical radiolucency1 year
      Spontaneous pain (3 teeth)2 years
      Extraction because of tooth and restoration fracture
      A summary of the clinical/radiographic signs and symptoms of the reported failed cases in the selected studies. It can be noticed that they could be divided into immediate/early (which are mainly associated with pulpitis/pain) and late/delayed failures (which are primarily associated with necrosis and periapical radiolucency).
      Supplemental Table S2Meta-regression Analysis of the Effect of Clinical Variables on the Success Rate (1 Year). Model 2. Model for Capping Material, Final Solution, Preoperative Pulp Diagnosis, and Type of Study
      Dependent variableWeighted mean 1-year success rate
      Independent variableCoefficient (95% CI)P value
      Capping materials (ref: CH)
       MTA0.03 (−0.09 to 0.15).639
      Final solution
       NaOCl (ref: no)0.03 (−0.15 to 0.20).766
       Saline (ref: no)−0.02 (−0.17 to 0.13).795
      Pulp diagnosis (ref: irreversible)
       Reversible0.38 (0.21–0.56).001
      Study type (ref: prospective)
       Randomized clinical trials−0.03 (−0.17 to 0.10).624
      CH, calcium hydroxide; CI, confidence interval; MTA, mineral trioxide aggregate; NaOCl, sodium hypochlorite.

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